Traditional Chart Overview

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Traditional Chart

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Also called block chart or source-oriented record

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Structure of Traditional Chart

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Divided into distinct areas or blocks

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Additional Components of Traditional Chart

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History and physical examination, medication sheet

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Data Representation in Traditional Chart

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Graphs and flowsheets

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Medical Reports in Traditional Chart

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Laboratory and x-ray reports

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Conclusion of Patient Care in Traditional Chart

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Discharge summary

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SOAP Model

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An extended model with the added "IER" components.

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R in SOAP

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Revision—any changes made to the original plan in response to the evaluation.

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Purpose of Implementation

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To administer the specific therapy plan.

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Extended SOAP Model

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Known as the SOAPIE or SOAPIER model.