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Get It Write

Justice Health and Forensic Mental Health Network
Project Added:
23 February 2016
Last updated:
17 October 2016

Get It Write

Summary

The Subjective, Objective, Assessment and Plan (SOAP) methodology was selected as a prescriptive documentation style for use in all nursing progress notes. Staff education and resources were provided to support the implementation of this methodology in clinical practice.

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Aim

To improve the quality of nursing clinical documentation used by the JH&FMHN , to 50% by December 2015.

Benefits

  • Improves the quality of nursing progress notes.
  • Reduces adverse events caused by poor clinical documentation.
  • Improves communication and handover processes with other members of the multidisciplinary team.
  • Improves patient care through accurate and timely clinical documentation.

Background

For more than a decade, root cause analysis investigations and NSW Coroner’s inquests have noted concerns with the quality and content of clinical documentation by nursing staff in the JH&FMHN . Previous activities to address these concerns and improve the quality of clinical documentation have included a statewide education program led by the governance unit and a mandated health record audit. These approaches did not improve the quality of documentation, or reduce the number of recommendations for improvement.

Implementation

  • A literature review was undertaken to assess the benefits of a range of clinical documentation models.
  • Stakeholder feedback and consultation was undertaken within working party focus meetings.
  • The SOAP methodology was selected as a prescriptive documentation style for use in all nursing progress notes. The SOAP methodology addresses the essential elements of quality documentation, to deliver a structured, accurate and complete account of patient care provided.
  • SOAP methodology information cards were developed for staff, for easy reference while completing nursing progress notes.
  • An audit tool was developed, to identify where the SOAP methodology was present in nursing progress notes.
  • An audit of nursing progress notes was conducted with 30 health records from Cooma Correctional Centre and Long Bay Hospital.
  • Education sessions were provided to all nursing staff at Cooma Correctional Centre and Long Bay Hospital.
  • Implementation audits were completed prior to and following staff education sessions, to evaluate awareness and understanding of the SOAP methodology in clinical practice.
  • A process was developed, so clinical documentation can be reviewed during the performance appraisal process (currently pending executive approval).

Project status

  • Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

  • Project start: 1 July 2015
  • Project finish: 2 December 2015

Implementation sites

  • Cooma Correctional Centre Health Centre
  • Long Bay Hospital

Partnerships

  • Clinical Leadership Program

Results

  • Prior to the project, staff were unaware or had little awareness of the SOAP methodology and its application.
  • The SOAP methodology has improved the standard of clinical documentation in the nursing progress notes, by addressing essential elements of patient care delivered by staff.
  • The post-education audit found there was a 59% improvement in the quality of clinical documentation.
  • The SOAP methodology has been mandated by the network as the approved method of documentation for clinical entries requiring assessment or intervention.
  • All nursing staff are now provided with information cards on lanyards.
  • Education on SOAP methodology is provided in the orientation program for all new clinical nurse educators, via the Health Education and Training Institute (HETI) online training.
  • Failure to meet the mandated medico-legal requirements of documentation covered in HETI online training, will be managed at an individual clinician level under the performance management framework.
  • The project team is seeking executive support to implement SOAP across NSW .

Lessons learnt

  • We found that once a couple of staff started to use the SOAP methodology in their clinical documentation, it increased the likelihood that others would follow, which resulted in better documentation standards.
  • We found that the SOAP methodology is only suitable for patient interactions where an assessment or action is required. There are situations were a single line entry is appropriate and SOAP is not required.

Further reading

Project team

  • Bernadette Hollis
  • Jonathan Lapitan
  • Rebecca Lucas
  • Lee Trevethan

Contact

Jonathan Lapitan
Clinical Nurse Educator
Justice Health & Forensic Mental Health Network
Phone: 02 9700 3274
Jonathan.lapitan@justicehealth.nsw.gov.au

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