# Situation: A 24-year-old man with schizophrenia is in his second week on a psychiatric ward that still uses paper records. Nurses write problem-oriented notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation), and routine assessments are recorded on flow sheets using charting by exception. Two days later a team member writes this SOAPIE note: S: Client states, "They are putting chemicals in my food." O: Ate 10% of lunch; lifted each lid and smelled the food; appeared suspicious. A: Food intake is limited by fear that meals are poisoned. P: Offer sealed, packaged food; weigh daily. I: Offered sealed crackers and a banana at 15:00. E: Ate both by 15:20; ate 60% of dinner served in sealed containers. Which part of the note should be rewritten?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630155  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 24-year-old man with schizophrenia is in his second week on a psychiatric ward that still uses paper records. Nurses write problem-oriented notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation), and routine assessments are recorded on flow sheets using charting by exception.

Two days later a team member writes this SOAPIE note:
S: Client states, "They are putting chemicals in my food."
O: Ate 10% of lunch; lifted each lid and smelled the food; appeared suspicious.
A: Food intake is limited by fear that meals are poisoned.
P: Offer sealed, packaged food; weigh daily.
I: Offered sealed crackers and a banana at 15:00.
E: Ate both by 15:20; ate 60% of dinner served in sealed containers.
Which part of the note should be rewritten?

## 보기

1. O, because one phrase is an impression, not an observed behavior **✔ 정답**
2. P, because daily weighing is a medical order, not a nursing plan
3. S, because delusional content should be paraphrased, not quoted
4. E, because it should restate the goal rather than intake amounts

**정답: 1**

## 해설

Objective data must describe only what was observed or measured. "Lifted each lid and smelled the food" is observed behavior, but "appeared suspicious" is the nurse's impression and should be removed or replaced with further observed behavior. The other parts are placed correctly: his words are quoted, the plan includes monitoring weight, and the evaluation reports measured intake.

## 심화 해설

Why the Objective section must be rewritten

The SOAPIE format is built on a clear division of labor: each section records a different type of information, and mixing those types undermines the legal and clinical usefulness of the note. In the O (Objective) section, the nurse is expected to record only what can be seen, heard, measured, or otherwise verified by another observer. The phrase “lifted each lid and smelled the food” meets that standard because it describes a discrete, observable action. “Appeared suspicious,” however, is not an observation; it is an inference the nurse drew from the patient’s behavior. Two nurses watching the same patient might agree that he lifted the lids and smelled the food, but they could reasonably disagree about whether he “appeared suspicious.” That subjectivity is what makes the phrase an impression rather than objective data.

Key point! In charting by exception and paper-based flow sheets, the narrative note is often the only place where unusual findings are described. If the nurse records an impression in the O section, the reader cannot tell which parts of the note are verifiable facts and which are the nurse’s interpretation. This matters for treatment planning, handoff communication, and any future legal review of the record.

The correct revision is to either delete “appeared suspicious” or replace it with additional observable behavior that supports the inference—for example, “scanned the room before eating” or “pushed the tray away when staff approached.” The assessment section is the appropriate place for the nurse to state the clinical interpretation that the behavior suggests paranoia or suspiciousness.

Why the other sections are correctly written

The S (Subjective) section quotes the patient’s exact words: “They are putting chemicals in my food.” Direct quotation is the standard for documenting delusional or paranoid statements because it preserves the patient’s own language without the nurse altering or softening the content. Paraphrasing risks introducing the nurse’s interpretation or minimizing the clinical significance of the statement. The quotation marks signal that these are the patient’s words, not the nurse’s conclusion.

The P (Plan) section includes offering sealed, packaged food and daily weighing. Daily weighing is a monitoring intervention that falls within nursing scope because it tracks the effectiveness of the nutritional plan and detects weight loss related to poor intake. It does not require a medical order; nurses routinely weigh patients as part of ongoing assessment and evaluation of care.

The E (Evaluation) section reports measured outcomes: the patient ate the crackers and banana by 15:20 and consumed 60% of dinner. Evaluation should describe what actually happened in relation to the plan, using concrete, measurable data such as intake percentages and times. Restating the goal would be redundant; the goal was already stated in the plan. The evaluation’s purpose is to document whether the intervention achieved that goal.

Clinical reasoning for the psychiatric setting

A patient with schizophrenia who believes his food is poisoned presents a safety and nutrition concern. The nurse’s plan to offer sealed, packaged food is a reasonable environmental modification that reduces the patient’s anxiety and increases the likelihood of adequate intake. Documenting the patient’s response with specific intake amounts allows the team to track whether the intervention is working over time.

Watch out! In a paper record system with charting by exception, the narrative note carries more weight because routine findings are not charted individually. Any statement in the O section that is actually an impression can mislead other team members into thinking the patient’s suspiciousness was directly observed rather than inferred. This is a common documentation error tested on licensure exams because it reflects a real risk in clinical practice.

The distinction between observation and inference is foundational to accurate nursing documentation. Objective data answer the question “What did I see, hear, or measure?” while impressions answer “What do I think it means?” The meaning belongs in the assessment, not the objective section.

## 임상 시나리오

SOAPIE Objective Section: Facts OnlySeparating observation from inference in nursing documentation
The O (Objective) section must contain only what can be seen, heard, measured, or verified by another observer. "Lifted each lid and smelled the food" is observable behavior; "appeared suspicious" is an inference and must be removed or replaced with further observed actions such as "scanned the room before eating".

In charting by exception, the narrative note is often the only place unusual findings are described. Mixing impressions into the O section makes it impossible for readers to distinguish verifiable facts from nurse interpretation, which compromises treatment planning, handoff, and legal defensibility.

CautionTwo nurses watching the same patient may agree on observable actions but disagree on whether he "appeared suspicious." Subjective wording in the O section weakens the clinical and legal value of the record.

## 핵심 개념

- **SOAPIE** — Documentation format: Subjective, Objective, Assessment, Plan, Intervention, Evaluation
- **Objective data** — Information that is observable, measurable, or verifiable by another person
- **Charting by exception** — Documentation method where only abnormal or significant findings are recorded on flow sheets
- **Delusion** — Fixed false belief not amenable to change despite conflicting evidence

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