Discussion questions 1
Gathering data for the subjective portion of the SOAP note can be difficult when a patient may not want to share information. When I teach communication skills to my nursing students, we spend much time discussing the importance of open-ended questions. Open-ended discussion questions encourage patients to answer with more than just a "yes" or "no" and often lead the conversation. If possible, we should try to use open-ended questions. Can you write an example of an question in both open and closed ended form
Open Ended: How do you see your Health in comparison to last week?
Discussion questions 2
Many facilities are moving toward more focused or problem centered charting. Many have adopted electronic or paper flowsheets that basically cover all the "normal" and basic information. I think the progress note that you are referring to is the older "narrative" note that we all used to write. It basically was a run down of each body system. For example, you may have written "patient alert and oriented X3, heart rate regular, afebrile," etc. Now with the flowsheets and electronic flowsheets, for each body system you "check" off the WNL (within normal limits) for each section and then you only document on the abnormals with a problem focused note. This is actually called documenting by exception since you are only really writing notes on the instances or issues with are not WNL.
Charting and record taking are daily activities and may be required to be done for multiple patients. In case of approaches like narrative charting, an entire summary of patient's condition is reported and this type of report is quite subjective in nature due to which it may be extremely time taking may end up reporting about various aspects of the patient’s health that may already be within normal limits. Hence, it is better to implement a charting process which briefly report about all the abnormalities that are supposed to be tackled immediately.
Discussion questions 3
Can any of you describe the charting systems that you have used in your own experience? What do you see as the benefits and/or downfalls of the system?
SOAP is one of the most commonly used charting systems today and having used the same it would be interesting to report a few advantages and disadvantages of the same.
Advantages
Disadvantages
SOAP has objective and structured format making it easy to find any information required.
All the information is available on the same page.
The format itself provides information about the required details and no as such training is required.
Only the abnormalities are captured, to ensure that the key improvement areas can be focused.
SOAP is considered to be cumbersome at times, considering the fact that each problem requires a separate entry into the sheet even if there is an overlapping between the problems.
Redundancy is another issue which is present due to the fact that care plan, problem lists and flow sheets require multiple entries.
Discussion questions 4
I just wanted to add something regarding documentation. When we chart anything in the medical chart, be it on paper or in the computer, it is a legal document that can be called into court. So, for sake the providing clear documentation, it is recommended that we stay away from just using the words normal, stable, etc. These are actually considered subjective unless the parameters are clearly defined. It is actually preferred to document the actual data. For example, something we used to use often was VSS (vital signs stable) but it would be better to write. VS: T (temperature) 98.9, P (pulse) 66, R (respirations) 20, BP (blood pressure) 136/62, O2 (oxygen saturation) 96% on room air. By listing the actual vital signs the documentation is objective and lists only the facts. Even if the vital signs were in a normal range, they may not be normal for that patient and if there was an incident that arose, at least there was clear documentation prior to the incident. It is a good habit to get into right from the start since it is very important to be as objective as possible in our documentation. While it is not wrong to use the words "normal" or "stable" it is just preferred to have the objective data completed. In your experience, do you see this type of documentation?
It is important to ensure as much as objectivity in the reports as possible so that it can be universally interpreted by the physician or any other person. In case of subjective entries like ‘the patient is normal’, it is hard to interpret the meaning as the world ‘normal’ cannot be defined within a certain limit.
