ADPIE stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation. The ADPIE nursing process helps to frame nursing documentation and includes:

• Assessment.  The school nurse collects and assesses comprehensive data pertinent to the student’s health or situation. 
• Diagnosis.  The school nurse analyzes the assessment data, identifies issues, prioritizes concerns, and formulates a nursing diagnosis.
• Planning.  The school nurse develops a plan, which includes specific goals, to achieve desired outcomes.
• Implementation.  The school nurse executes the plan using evidenced based interventions.
• Evaluation.  The school nurse assesses, and reassesses, when necessary, progress towards attainment of outcomes/goals.

SOAPIE stands for Subjective, Objective, Assessment, Plan, Intervention, and Evaluation. Each of these elements represents an essential step in nursing documentation:

• Subjective.  The information you gather directly from the patient, such as symptoms or feelings. Being thorough at this stage can directly impact the accuracy of your assessment.
• Objective.  Pertains to observable and measurable data, like vital signs, lab results, or physical exam findings.
• Assessment.  Your professional interpretation of the subject and objective data, leading to possible diagnoses.
• Plan.  Outlines a series of actions or treatments to address the assessment.
• Intervention.  Involves implementing the plan and documenting each step taken during patient care.
• Evaluation.  A necessary step in which you monitor the patient’s reaction to intervention, adjust the care plan accordingly, and document the results.

These SOAPIE elements form the basis of the nursing process, guiding your work from initial patient contact through ongoing care.

SBAR stands for Situation, Background, Assessment, and Recommendation. SBAR is a common communication technique. The SBAR format can be used in nursing documentation of a communication:

• Situation.  A concise statement of the problem. What is going on now?
• Background.  Pertinent and brief information related to the situation. What has happened?
• Assessment.  Analysis and considerations of options. What you found/think is going on.
• Recommendation.  Request/recommend action. What you want done.