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ÀÛ¾÷Ä¡·áÀÓ»ó½Ç½À CASESTUDY SOAPnote / 1. Client Profile 2. Subjective information 3. Objective information 4. Assessment 5. Plan / 1. Client Profile Client Profile ºÎºÐ¿¡¼´Â ÀÛ¾÷Ä¡·á ´ë»óÀÚÀÇ ¹è°æ°ú Ư¼ºÀ» »ó¼¼ÇÏ°Ô »ìÆ캻´Ù. ÀÌ Å¬¶óÀ̾ðÆ®´Â 50¼¼ÀÇ ³²¼ºÀ¸·Î, ÃÖ±Ù¿¡ ³úÁ¹ÁßÀ¸·Î Áø´Ü¹Þ¾Ò´Ù. ³úÁ¹ÁßÀ¸·Î ÀÎÇÑ ÁÂÃø ½Åü ¸¶ºñ°¡ ÀÖ¾î, ÀÏ»ó»ýÈ°¿¡¼ ¿©·¯ °¡Áö ¾î¡¦ |
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¼ºÀΰ£È£½Ç½À SOAPLE 1, ³×·¯Æ¼ºê1 (³«»ó,´ç´¢) °èȹ ¼öÇà 3°³¾¿. / 1. °£È£°úÁ¤ (SOAPLE) 2. °£È£³×·¯Æ¼ºê / 1. °£È£°úÁ¤ (SOAPLE) SOAPLE´Â °£È£ °úÁ¤¿¡¼ »ç¿ëµÇ´Â ±¸Á¶ÈµÈ ÇüÅÂÀÇ ¹®Á¦ ÇØ°á Á¢±Ù ¹æ½ÄÀÌ´Ù. SOAPLEÀº ÁÖ°üÀû ÀÚ·á(Subjective), °´°üÀû ÀÚ·á(Objective), °£È£ ¹®Á¦(Assessment), °èȹ(Plan), ¼öÇà(Implementation), Æò°¡(Evaluation)·Î ±¸¼ºµÈ´Ù. ÀÌ Ã¼°è¸¦ ÅëÇØ¡¦ |
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¼ºÀΰ£È£ÇнǽÀ-SOAPLE 1°³,°£È£³×·¯Æ¼ºê 1°³ / 1. °£È£°úÁ¤ (SOAPLE) 2. °£È£³×·¯Æ¼ºê / 1. °£È£°úÁ¤ (SOAPLE) SOAPLEÀº ¼ºÀΰ£È£ÇнǽÀ¿¡¼ °£È£°úÁ¤À» ü°èÀûÀ¸·Î Á¤¸®ÇÏ°í ±â·ÏÇÏ´Â ¹æ¹ýÀÌ´Ù. SOAPLEÀÇ °¢ ¿ä¼Ò´Â ȯÀÚÀÇ °Ç° »óŸ¦ ÀÌÇØÇÏ°í, ±×¿¡ µû¸¥ ÀûÀýÇÑ °£È£ ¹®Á¦¸¦ ÆľÇÇϸç, ¸ñÇ¥¸¦ ¼³Á¤ÇÏ°í, °£È£ ÁßÀ縦 °èȹÇϸç, ±× È¿°ú¸¦ Æò°¡ÇÏ´Â °úÁ¤À» Æ÷ÇÔÇÑ´Ù. À̸¦ ÅëÇØ ¡¦ |
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ÀÛ¾÷Ä¡·áÀÓ»ó½Ç½À CASESTUDY SOAPnote / 1. Client Profile 2. Subjective information 3. Objective information 4. Assessment 5. Plan / 1. Client Profile Client ProfileÀº Ŭ¶óÀ̾ðÆ®ÀÇ ¹è°æ, »óȲ, ±×¸®°í Çʿ並 Æ÷°ýÀûÀ¸·Î ÀÌÇØÇÏ´Â µ¥ Áß¿äÇÑ ¿ªÇÒÀ» ÇÑ´Ù. º» »ç·Ê¿¡¼ Ŭ¶óÀ̾ðÆ®´Â 35¼¼ ³²¼ºÀÌ´Ù. À̸§Àº ±èö¼öÀ̸ç, ¿ÜºÎ¿¡¼ ÀÎÅ׸®¾î µðÀÚÀ̳ʷΠÀÏÇÏ°í ÀÖ´Ù. ±×´Â¡¦ |
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¡¥. °£È£°úÁ¤ 1) Problem List 2) SOAPIE chart A. °£È£»çÁ¤(Nursing Assessment) Á¤½Å°£È£ÇÐ ¿µÈ ºí·¢½º¿Ï¿¡¼ ÁÖÀΰø ³ª¿À¹Ì ¿ÓÃ÷°¡ ¿¬±âÇÏ´Â ´Ï³ª ¼¼¾î½ºÀÇ Á¤½Å»óŸ¦ Æò°¡Çϱâ À§ÇØ ±íÀÌ ÀÖ´Â °£È£»çÁ¤ÀÌ ÇÊ¿äÇÏ´Ù. ´Ï³ª´Â ¹ß·¹¸®³ª·Î¼ÀÇ ¿Ïº®ÇÔÀ» Ãß±¸Çϸç ÀÚ½ÅÀÇ ³»¸é¿¡¼ ½É°¢ÇÑ °¥µîÀ» °Þ°í ÀÖ´Ù. ±×³à´Â ¾î¸Ó´ÏÀÇ °úµµÇÑ ±â´ë¿Í ¾Ð¹Ú, ÀÚ½ÅÀÇ ºÒ¾È°ú ±äÀå°¨, ±×¸®°í °æÀïÀû¡¦ |
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´«, ±Í, ÇǺΠÁúȯÀÇ °£È£¹®Á¦ È®ÀÎ ¹× °£È£°úÁ¤ Àû¿ë (SOAPIE Çü½Ä) / 1. ½Ã³ª¸®¿À (»ç·Ê) 2. °£È£°úÁ¤ Àû¿ë 1) ¸Þ´Ï¿¡¸£º´ Áõ»ó ¾ÇÈ¿Í °ü·ÃµÈ ¿À½É 2) ÇöÈÆÀÇ ±Þ¼º ¹ßÀÛ°ú °ü·ÃµÈ ³«»ó À§Ç輺 / 1. ½Ã³ª¸®¿À (»ç·Ê) ȯÀÚ´Â 65¼¼ ³²¼ºÀ¸·Î, ÃÖ±Ù 2ÁÖ µ¿¾È Áö¼ÓµÈ ´« °¡·Á¿òÁõ°ú ºÓÀº ¿°Áõ, ±Í¿¡¼ÀÇ °¡º¿î ÅëÁõ°ú °¡·Á¿ò, ÇǺο¡ ¹ß»ýÇÑ ¹ßÁøÀ» È£¼ÒÇÏ¸ç ³»¿øÇÏ¿´´Ù. ȯÀÚ´Â °ú¡¦ |
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1. Nursing narrative Nursing Narrative´Â ȯÀÚÀÇ °Ç° »óÅÂ¿Í °£È£ °úÁ¤¿¡ ´ëÇÑ ÀÚ¼¼ÇÑ ±â·ÏÀ» Æ÷ÇÔÇÏ´Â Áß¿äÇÑ ¹®.. / 1. Nursing narrative 2. Self Study 3. SOAPIE / 1. Nursing narrative Nursing Narrative´Â ȯÀÚÀÇ °Ç° »óÅÂ¿Í °£È£ °úÁ¤¿¡ ´ëÇÑ ÀÚ¼¼ÇÑ ±â·ÏÀ» Æ÷ÇÔÇÏ´Â Áß¿äÇÑ ¹®¼·Î, °£È£»ç¿Í ´Ù¸¥ ÀÇ·á Á¦°øÀÚµé °£ÀÇ È¿°úÀûÀÎ ÀÇ»ç¼ÒÅëÀ» µµ¿ÍÁØ´Ù. ÀÌ·¯ÇÑ ³»·¯Æ¼ºê¡¦ |
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¼ºÀΰ£È£ÇÐ A£« [°£°æÈ, À§¾Ï] ³»·¯Æ¼ºê¿Í SOAPIE (£«ÀÚ°¡ÇнÀ, ½Ç½À¼Ò°¨¹®) / 1. °£È£°úÁ¤(SOAPIE) & °£È£ ³»·¯Æ¼ºê(Nursing narrative) 1) 1ÁÖÂ÷ - SOAPIE 1. 2) 1ÁÖÂ÷ - Nursing narrative 1. 3) 2ÁÖÂ÷ - SOAPIE 2. 4) 2ÁÖÂ÷ - Nursing narrative 2. 2. ÀÚ°¡ÇнÀ(Self study) 1) Æó¾Ï°ú °£°æº¯Áõ 2) °£°æº¯ÁõÀÇ ¾à¹°°ú À§¾Ï 3) À§¾Ï ¼ö¼ú ÈÄ ÇÕº´Áõ°ú °£È£ 4) ¹ÐºÀÈä°ü¹è¾×°ú Æó¡¦ |
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1. °£È£·Â °£È£·ÂÀº ȯÀÚÀÇ °Ç° »óŸ¦ ÀÌÇØÇÏ°í ÀûÀýÇÑ °£È£¸¦ Á¦°øÇϱâ À§ÇØ ÇʼöÀûÀÎ Á¤º¸ÀÇ ÁýÇÕÀÌ´Ù. MICU¿¡¼ ȯÀÚ°¡ °¡Áø ´Ù¾çÇÑ °Ç°.. / 1. °£È£·Â 2. ÇöÀç º´·Â 3. Áúº´ ¹× ¼ö¼ú¿¡ ´ëÇÑ ¹®Çå °íÂû 4. °£È£ÀÏÁö ³»¿ë 5. Âü°í¹®Çå / 1. °£È£·Â °£È£·ÂÀº ȯÀÚÀÇ °Ç° »óŸ¦ ÀÌÇØÇÏ°í ÀûÀýÇÑ °£È£¸¦ Á¦°øÇϱâ À§ÇØ ÇʼöÀûÀÎ Á¤º¸ÀÇ ÁýÇÕÀÌ´Ù. MICU¿¡¼ ȯÀÚ°¡ °¡Áø ´Ù¾ç¡¦ |
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¥°. ¼·Ð Objective), °£È£ Áø´Ü(A Assessment), °èȹ(P Plan), ÁßÀç(I Intervention), Æò°¡(E Eva.. / ¥°. ¼·Ð 1. ¿¬±¸ÀÇ Çʿ伺 ¹× ¸ñÀû 2. ¿¬±¸±â°£ ¹× ¹æ¹ý 3. ¹®Çå°íÂû ¥±. °£È£»çÁ¤ 1. °£È£»çÁ¤ 2.ÀϹÝÀû Á¤º¸ ¹× ȯÀÚ °£È£·Â 3. Áø´ÜÀû °Ë»ç 4.Åõ¿© ¾à¹° 5.°£È£»çÁ¤ ¹× Áø´Ü ¥². °á·Ð ¹× Âü°í¹®Çå 1.°á·Ð¼Ò°¨ 2.Âü°í¹®Çå / ¥°. ¼·Ð Objective), °£È£ Áø´Ü(A Asses¡¦ |
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