DOCUMENTATION USING SOAPIE

Nursing Documentation  This format is part of the problem-

oriented medical record system of
 Vital component of safe, ethical, and documentation which describes
effective nursing practice. patient problems on multidisciplinary
 Describes Nurses’ accountability progress notes.
and expectations for documentation
in all practice settings Subjective Data- information the patient or
family members tell you, such as chief
Documentation complaint
 a nursing action that produces a Objective Data- factual, measureable data
written and/or electronic account of you gather during the assessment (vital
pertinent client data, nursing clinical signs, lab test values)
decisions and interventions, and the
client’s responses in a health record Assessment Data- conclusions based on
(Perry, Potter, Stockert & Hall 2017). the collected subjective and objective data
 an integral part of professional and formulated as patient problems or
nursing and safe practice. nursing diagnoses.
 Documentation is not optional
Plan- strategy for relieving patient’s
Confidentiality problems including immediate or short-term
actions and long term measures.
 Health care professionals should
view the security of client Intervention- measures taken to achieve an
documentation as a serious issue. expected outcome.
 Failure to comply with legislation, Evaluation- An analysis of the effectiveness
falsifying information or providing of the interventions. If expected outcomes
information without the client or fall short, develop alternative interventions.
agency’s consent may constitute
professional misconduct.

SOAPIE The Purpose of Nursing Documentation

1. Subjective Data  creation of a database or a health
2. Objective Data record of a client and their
3. Assessment Data experience with the health care
4. Plan system.
5. Intervention  demonstrates what the nurse does
6. Evaluation for/ with the client.
 One part of the broader
SOAPIE (cont.) interprofessional documentation that
 Follows a structured method to write forms the client health record
narrative progress notes.

Fundamentals of Nursing Reviewer 2019 - SRBC

 Guidelines in reporting related to Data
client care
 written in the narrative and contains
• BE honest, accurate and non-offensive only subjective & objective data
 lays the supporting evidence for why
• DO not breach patient's confidentiality you are writing the note. You are
letting the reader know “this is what
• WRITE legibly and key-in competently
the patient is saying and what I’m
to computer systems
seeing”.
• Sign all entries
Action
• All entries should be dated and timed
as close to the actual time of event  the “verb” area.
 Write what you did about the
• Records must accurate and clear that findings
the patient will surely understand  Includes the nursing interventions.
 Planning and implementation phase.
• Focus on facts, not speculation
Response
• Avoid unnecessary abbreviations
 How the patient responded to action
Guidelines in reporting related to  Not added until patient outcome is
client care (cont.) evident.

2. Electronic Health Record

1. Focus, Data, Action, Response  an electronic version of a
(FDAR) patient’s medical history.
 maintained by the provider
 It is a method of charting over time, and may include
nurses use. all of the key administrative
 It is geared to save time and clinical data
decrease duplicate charting.  including demographics,
 It is a great charting method progress notes, problems,
for nurses who have a lot of medications, vital signs, past
patients and is easier read by medical history,
other professionals. immunizations, laboratory
 It gives other professionals a data and radiology reports.
snapshot of what went on  ability to support other care-
during your shift in a concise related activities, including
manner. evidence-based decision
support, quality
management, and outcomes
reporting.
Focus  EHRs are the next step in the
continued progress of
 This is the subject/purpose for the healthcare that can
note. (Nursing Diagnosis, Event, strengthen the relationship
Patient Event or Concern, The nurse between patients and
must identify the content or purpose clinicians.
of the narrative entry)

Fundamentals of Nursing Reviewer 2019 - SRBC

 3. Problem Oriented Medical Record
(POMR)
 mainly used for managing Change of Shift Report
chronic illness
Purpose
 Daily progress notes are
maintained by the care team  responsibility and accountability
and are used to record every  Report is therefore informational
problem proved to be very details
successful in providing a  Report can also be educational.
structure that helps doctors
 Insure continuity of care giving and
record their notes about
patient safety.
patients
 POMR preserves thedata in Incident Report
an easily accessible way that
encourages ongoing Defining an Incident
assessment and revision.
 an incident is any event that affects
patient or employee safety.
 In most healthcare facilities, injuries,
ISBAR Framework patient complaints, medication
errors, equipment failure, adverse
 Introduction- Who you are, your role,
reactions to drugs or treatments, or
where you are and why you are
errors in patient care must be
communicating
reported.
 Situation- What is happening at the
moment?
 Background- What are the issues
that led up to this situation? There are types of incidents:
 Assessment- What do you believe
the problem is? 1. Near miss: did not result in harm or
 Recommendation- What should be damage
done to correct this situation. 2. Adverse events: arising during
Advantages of ISBAR clinical/non-clinical care, unwanted harm.

3. Sentinal events: unexpected incident,

 Ensures completeness of
information which leads to death or major loss of
function
 easy and focused way to set
expectations for what will be Incident Report (cont.)
communicated
 Ensures a recommendation is clear  Also called an event report or
and professional occurrence report
 is a formal report written by
Who can use ISBAR? practitioners, nurses, or other staff
1. Doctor to doctor members.
2. Nurse to nurse  It is a requirement of all hospital staff
3. Nurse to doctor that they report any incident.
4. Doctor to allied health  They should provide basic facts.
 Be thorough and accurate.

Fundamentals of Nursing Reviewer 2019 - SRBC

Purpose: To inform facility administrators of Characteristics of Incident Reporting
incidents that allow the risk management Systems
team to consider changes that might
prevent similar accidents  Institution must have a supportive
environment for event reporting that
protects the privacy of staff who
report occurrences.
 Reports should be received from a
broad range of personnel.
 Summaries of reported events must
be disseminated in a timely fashion.
 A structured mechanism must be in
place for reviewing

Referral System

Level 1

Primary Health Care clinic Community

Health Care Centre

District Hospital

Level 2

Regional Hospital

Level 3

Provincial tertiary system hospital

Level 4

Central Hospitals

Specialized Hospitals

Fundamentals of Nursing Reviewer 2019 - SRBC