Get It Write
23 February 2016 Last updated:
17 October 2016
Get It Write
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.
To improve the quality of nursing clinical documentation used by the JH&FMHN , to 50% by December 2015.
- 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.
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.
- 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).
- Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.
- Project start: 1 July 2015
- Project finish: 2 December 2015
- Cooma Correctional Centre Health Centre
- Long Bay Hospital
- Clinical Leadership Program
- 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 .
- 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.
- NSW Health Government. Health Care Records: Documentation and Management [Internet]. 2012 [cited 24 September 2015].
- EMR Consulting Services. FAQ: SOAP notes [Internet]. 2010 [cited 24 September 2015].
- Cameron S, Turtle-Song I. Clinic Procedures [Internet]. 2002 [cited 24 September 2015].
- Mootz R. Maximizing the effectiveness and efficiency of clinical documentation [Internet]. 2012 [cited 24 September 2015].
- Weed L. Medical records that guide and teach. New England Journal of Medicine 1968; 278(11): 593-600.
- Whitehead S. The EMT Spot [Internet]. 2009 [cited 24 September 2015].
- Bernadette Hollis
- Jonathan Lapitan
- Rebecca Lucas
- Lee Trevethan
Clinical Nurse Educator
Justice Health & Forensic Mental Health Network
Phone: 02 9700 3274
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