# Situation: A 67-year-old man is on the medical ward on day 4 after an ischemic stroke with right-sided weakness. The ward uses a problem-oriented record with nursing progress notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation), kept in an electronic health record. His care plan states the expected outcome: "By day 5, the client will walk 10 m in the hallway with a quad cane and the standby assistance of one person." On day 5 he does so. Which Evaluation entry in his SOAPIE note is BEST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630560  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 67-year-old man is on the medical ward on day 4 after an ischemic stroke with right-sided weakness. The ward uses a problem-oriented record with nursing progress notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation), kept in an electronic health record.

His care plan states the expected outcome: "By day 5, the client will walk 10 m in the hallway with a quad cane and the standby assistance of one person." On day 5 he does so. Which Evaluation entry in his SOAPIE note is BEST?

## 보기

1. Walked 10 m in hallway with quad cane, one person on standby. Outcome met. **✔ 정답**
2. Walked in hallway with quad cane and tolerated activity well. Outcome met.
3. One nurse stood by as he walked in hallway with quad cane. Plan continued.
4. Seems stronger and more confident walking with quad cane. Outcome met.

**정답: 1**

## 해설

The Evaluation part compares the client's measured response with the expected outcome and states whether it was met, partially met, or not met. The entry must contain the same measures as the outcome (distance, device, assistance) so that the judgment can be checked.

## 심화 해설

What the Evaluation part must do
In a SOAPIE note, the Evaluation (E) compares the client's measured response with the expected outcome written in the care plan and states whether the outcome was met, partially met, or not met. The expected outcome here is precise: by day 5, walk 10 m in the hallway with a quad cane and the standby assistance of one person. A good evaluation entry repeats the same measures as the outcome, so anyone reading the note can check the judgment against the data. The best entry states that he walked 10 m in the hallway with a quad cane and one person on standby, and that the outcome was met.

Why measurable criteria matter
Expected outcomes are written in measurable terms, often with a subject, action, criteria, conditions, and time frame. Here the criteria are distance (10 m), device (quad cane), and level of assistance (standby of one person), with a time frame of day 5. When the evaluation leaves out any of these, the reader cannot tell whether the outcome was truly met. For example, walking 3 m with two people holding him would not meet this outcome, even if he tolerated it well.

| Entry | Contains outcome measures? | Judgment stated? |
| --- | --- | --- |
| Walked 10 m, quad cane, one on standby. Outcome met. | Yes | Yes |
| Walked in hallway, tolerated well. Outcome met. | No distance or assistance | Yes, but unsupported |
| One nurse stood by as he walked. Plan continued. | No distance | No outcome judgment |
| Seems stronger and more confident. Outcome met. | No, subjective impression | Yes, but unsupported |

Why the other entries are weaker
"Tolerated activity well" is vague and omits the distance and assistance, so the judgment cannot be checked. The entry describing a nurse standing by is really an Intervention note and gives no judgment on the outcome; "plan continued" fits a not-yet-met or ongoing outcome, not one that was achieved. "Seems stronger and more confident" is an impression, not measured data, and documentation should be objective.

Documentation principles
Notes should be objective, specific, and measurable. Avoid vague words such as "good," "well," or "seems." Using the outcome's own criteria in the evaluation also guides the next step: if met, a new outcome can be set, such as walking 20 m or walking with supervision only.

Exam takeaway
Key point A strong Evaluation entry = the client's measured response using the outcome's own criteria + a clear judgment (met, partially met, not met).

## 임상 시나리오

Writing the Evaluation in SOAPIEMatching the expected outcome
The Evaluation compares the client's measured response with the expected outcome and states whether it was met, partially met, or not met.

Repeat the outcome's measures: distance (10 m), device (quad cane), and assistance (one person on standby).

Avoid vague words such as "tolerated well" or "seems stronger," which cannot be checked against the outcome.

CautionAn entry that describes only what the nurse did is an Intervention note, not an Evaluation.

## 핵심 개념

- **SOAPIE** — A problem-oriented note format: Subjective, Objective, Assessment, Plan, Intervention, Evaluation.
- **Expected outcome** — A measurable statement of the client response the care plan aims to achieve by a set time.
- **Quad cane** — A cane with a four-pronged base that gives more stability than a single-point cane.
- **Standby assistance** — A helper stays close and ready to assist but does not physically support the client.

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