S: Situation (WHAT IS GOING ON)

B: Backgroun (WHAT HAS HAPPENNED)

A: Assessment (WHAT DO YOU THINK IS WRONG)

R: Recommendations (WHAT WOULD YOU SUGGEST HAPPEN)

P: Provocation/palliation

What makes the pain better of worse?

Q: Quality/quantity

What does the pain feel to you?(quality) How often does it happen?(quantity)

R: Radiation/region

Where is it? Does is spread?

S: Scale/severity

Rate your pain on a scale of 1 to 10

T: Timing/time of onset

Is there a pattern? Does it come on quickly or slowly?

U: Understanding

What do you think this pain it?

1. Hemoglobin: RBC, 140-180 male, 120-160 female
2. White blood cell count (infection): 5-10x10^9L
3. Platelets (clotting): 150-400x10^9

A - Asymmetry

B - Border

C - color variation

D - Diameter > 6mm

E - Elevation and enlargement

S: Subjective

O: Objective

A: Assessment (ex: enhanced health-seeking behavior request for info on skin self-exam)

P: Plan (ex: teach self-care behavior)

C: Cut down: feel need to cut down

A: Angry: angry when people confront you

G: Guilty: feeling guilty of drinking

E: Eye opener: ever drink in the morning?

1. Weakness
2. Trouble speaking
3. Vision problems
4. Headache
5. Dizziness

• A: Appearance
• B: Behavior
• C: Cognition
• T: Thought processes

• Problem (P): brief statement of the patient's potential or actual health problem
• Etiology (E): a brief description of probable cause, contributing or related factors
• Signs & Symptoms (S): list of the cluster of the objective and subjective data that lead the nurse to pinpoint the problem

• D: Data: objective and subjective data (just the data that help you determine which action to take)
• A: Analysis: of patient's concern/need. Impression of the data that inform actions
• R: Response: what happened to patient as a result to intervention, action, responses to care, patient outcomes
• P: Plan: goals to achieve in a designated period of time

• G: Gravida: previous pregnancies, regarless of outcome
• T: Term
• P: Preterm
• A: Abortion
• L: Living