In this post, we continue our discussion of documentation with methods of documentation.

Methods of Documentation: Narrative Note

In narrative documentation, a summary of the care provided is written in paragraph form. The patient’s status should be described in detail, as well as all treatments and nursing interventions performed and the patient’s response to those interventions. Narrative notes may often be long, and may include the routine care given as well as significant findings and patient problems. When used in conjunction with appropriate flowsheets, the note may be shortened by including only significant findings, interventions and responses.

ADVANTAGES:

• Narrative documentation can be easily integrated with the use of flowsheets and other documentation tools.
• In emergency situations, events can be documented easily in chronological order.

DISADVANTAGES:

• Lack of structure in the narrative note often results in a disorganized, haphazardly flowing document that is extremely difficult to follow.
• Narrative notes are time consuming to write and do not include all of the components of the Nursing Process, specifically planning and evaluation are often not included.
• Narrative notes do not easily allow for the review and tracking of the patient ‘s current status and current problems. This makes the evaluation of the effectiveness of nursing care difficult.
• Critical thinking and decision making, the nurse’s data analysis skills and the rendering of a subsequent conclusion is not always reflected in the Narrative note.
• Due to the lack of uniform criteria for the Narrative note, it is difficult to extract information for quality improvement activities, research and monitoring.

Methods of Documentation: SOAP Note

First designed for physician use, the Problem-Oriented method of documentation includes a problem list and a consistent pattern of entries that refer to one or more problems documented for the patient. Each entry minimally includes a Subjective, Objective, Assessment and Plan section.

Subjective:

The Subjective information should contain the patient’s description of his/her symptoms, concerns, and feelings, for example “My stomach still hurts”; “When I went to the bathroom there was blood”; “I feel better today”. It is why the patient is seeking care and may include the patient’s answers to questions asked. It is important to use direct quotes whenever possible. Subjective information may include such details as when the symptoms began, location, intensity, duration and what relieves the symptom. The Subjective should be pertinent to one or more problems on the Problem List. It should be written so that it is clear which concern is being addressed.

Objective:

The Objective information includes vital signs and physical assessment; the actual observations that are made regarding the patient or their complaint. This information may include lab results. Objective information should be specific, for example, the size of a wound should be described in length and width (2.5 cm long and .5 cm wide), the amount of drainage should be quantified ( 5 cc of serosanginous fluid), ‘abdomen soft, non-tender to palpation; positive bowel sounds X 4’; “BP 128/78, P 100, R 24, T 101.8 ℉, A & O X 3, pupils 3mm bilaterally”.

Assessment:

The Assessment refers to what you, the nurse, believe to be going on with the patient based upon the subjective and objective data obtained during the encounter. This analysis is usually written as a Nursing Diagnosis (reference the NANDA-I list).

Plan:

The Plan is the action that will take place based upon the Subjective and Objective information. It will address the stated Nursing Diagnosis. The Plan includes immediate and future actions, diagnostic and therapeutic regimens, and discharge plans, if applicable. For example, ‘medicate per MD order’; ‘encourage hydration with po fluids at bedside’; ‘maintain patient safety by implementing close watch, notify MD Smith of mental status change’ are appropriate entries for a Plan. Be sure to include any follow-up instructions, even if it is “return to clinic as needed”.

ADVANTAGES:

• SOAP charting adds structure and uniformity to the health record.
• The nursing process is reflective in the SOAP format – assessment, diagnosis, plan, intervention and evaluation are all included in the documentation.
• The SOAP format allows the standardization of care plans, which in turn, allows nursing to document that the plan of care was implemented clearly through their progress notes.
• Usually, SOAP charting is used in an integrated health record. The patient’s issues and progress can be seen chronologically through the assessments of all caregivers, which encourages collaboration and enhanced communication.
• The problem-oriented approach allows the tracking of particular problems more easily for quality improvement monitoring.

DISADVANTAGES:

• Moving to a SOAP format requires some nursing education and practice to ensure that the correct pieces of information are placed in the correct heading. Sometimes, nurses omit one or more of the categories (SOAP), which defeats the purpose of the documentation.
• If there are also flowsheets in use, there may be some redundancy as the nurse documents interventions and treatments on the SOAP note and the flowsheet.
• Since each problem must have its own SOAP note, this may make more work for the nurse. It also may result in redundancy, as the nursing assessment may be duplicated in the documentation for more than one problem. SOAP notes should NOT be combined for more than one problem, even if the assessment and interventions are the same.

This post based on The Correctional Nurse Educator class entitled Documentation for the correctional Nurse. Which method of documentation do you like, and why?