First Encounter in the SOAP note arena
Documentation is important in nursing as it allow the nurses to communicate about care providers. The communication can be written or electronically about the client (D’Antonio & Whelan, 2009). SOAP Notes documentation is different from the NP to nursing documentation as it is a problem-oriented approach where nurse endeavor to identify and list the problems facing the clients. Documentation is SOAP notes follows a given structure as defined by the acronyms of the word SOAP, subjective, objective data, assessment, plan, intervention and revision (College of Registered Nurses of British Columbia. (2013). The current nursing documentation has advanced into electronic which requires the nurse to exercises discretion and clarity when inputting the data in according to the guidelines.
When comparing Nurse Practice and Registered Nursing, the documentation is similar because, it is required that the nurse adheres to the method of taking notes when inquiring and recording information about the client. The process of data recording is similar. The areas that I view challenging in SOAP notes documentation is that it is subjective and this may lead to failure to capture the situation of the clients. Asking the client about questions on how they feel may not work in some scenarios where the client may not be able to communicate hence resulting to subjectivity that may lead to wrong diagnosis.
These challenges are however manageable. One of the things required is to ensure that initial client’s information is well kept and is used in cases whether such patients cannot express how they feel. The practitioners should also use various methods to ascertain what the patient is feeling such as observing and carrying out preliminary tests to determine where the problem is (Timmins, 2008). This will help reduce the challenges and ensure that information is well documented.
References
College of Registered Nurses of British Columbia. (2013). Nursing documentation. Retrieved from https://www.crnbc.ca/Standards/Lists/StandardResources/151NursingDocumentation.pdf
D’Antonio, P., & Whelan, J. (2009). Counting nurses: the power of historical census data, Journal of Clinical Nursing, 18(19): 2717-2724.
Timmins, F. (2008). A critical review of appropriate conceptual models for use by coronary care nurses, International Nursing Review, 55(1):117-124.
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