Documentation Essentials
With this introductory post on documentation, we will briefly cover why we document, what to include in our documentation, and how to maximize the use of SOAP charting. We’ve all heard of SOAP, but are we using it to maximize our efficiency and accuracy during busy clinical days?
Why do we document?
Documentation is a major part of our role as health care professionals. Across nursing disciplines and settings, documentation is included in our professional standards. The purpose of documentation is to accurately reflect the needs of the patient, the treatments and interventions provided, and patient outcomes (1, 2). Documentation is needed for continuity of patient care, communication among healthcare providers, and for legal defence (3, 4). Accurate and timely documentation results in better patient outcomes (3). It’s helpful to read our individual nursing professional standards on documentation. Most, if not all, regulatory nursing colleges will have guidance on documentation standards.
What should be included in our documentation?
It’s common for charting to take up a lot of time. This begs the question: what strategies can we implement into daily practice to ensure our charting is both efficient AND accurate? First, let’s go back to basics. What pertinent information should we include in our documentation?
Document the care or service provided.
Document in the correct patient chart with a stamp or signature.
Document a timeline or time stamp the note.
Document the rationale for why the care was provided.
Document patient response and outcomes.
Document informed consent and informed choice discussions as appropriate.
Be objective, avoid subjective descriptions. Use direct patient quotes and describe direct observations. (1)
How can we organize our documentation?
First, a note on charting templates. Many clinicians use charting templates with editable fields, that can serve as a mental checklist during a patient encounter. This helps guide the history, physical exam, and differential diagnosis. This structure can help clinicians remember must-not-miss diagnoses in certain clinical encounters. Charting templates can save you time during a busy shift and can help ensure you aren’t missing pertinent clinical information during the clinical encounter. Templates can reduce documentation time, enforce standards, aid chart review, and provide decision support (5). They help summarize what the most likely diagnosis is, how the must-not -miss diagnoses were ruled out, and rationale for ordering tests or performing procedures (1). Many work places will have charting templates to use, you can make your own, or gather ideas from colleagues who use templates.
BOTTOM LINE: try using a charting template - does it help you remember information, including the must-not-miss diagnoses?
But like copy-pasting, templates can have inaccurate information, including unreconciled medication lists or default exam findings that were not actually observed. It’s important to read through your charting to acknowledge your own observations, especially if you didn’t make the template yourself (5). Further, templates don’t necessarily work for every patient presentation. It’s meant to speed up charting time and provide mental reminders, but does not replace the diagnostic reasoning process that is much more complex than following a checklist.
There are many opinions on how nurses should chart. We’re taught various strategies through school, we learn from colleagues, and we follow organizational standards as well. Many nurses follow workplace expectations. Every clinician charts differently based on preference. We will focus on a charting structure universally used for patient encounters to guide differential diagnoses and treatment plans – the SOAP method.
SOAP charting
This stands for subjective information, objective information, assessment (what is the diagnosis or differential diagnosis) and plan. This is a popular format for nurse practitioners, physician assistants, and physicians across healthcare settings. This format helps clinicians use clinical reasoning to assess, diagnose, and treat a patient based on the information gathered (6). This structure provides information about the health care status of a patient and is a great communication tool between providers (6).
The style includes bullet sentences (instead of narrative descriptions) which leads to a concise summary of our diagnostic impression and recommendations. This form of charting is usually less laborious compared to narrative charting and can be clearly read and understood by other health care providers. This structured format serves as a cognitive aid and helps retrieve pertinent information (6). Further, it can be used to structure notes if we decide to refer or consult a specialist. I’ve developed several SOAP charting templates with checklists that were especially helpful as a new graduate, and still help me to this day. There are ways to upload templates into electronic medical records with automatic functions that further saves time.
SUBJECTIVE: includes the patient’s chief complaint, history of presenting illness, medical history, surgical history, family history, social history, socioeconomic status, substance use, review of systems, medications, allergies, and other historical information. Narrow your review of systems to pertinent positives and negatives relating to the clinical scenario.
OBJECTIVE: includes vitals, physical exam findings, and diagnostic test results.
ASSESSMENT: can include a summary of the chief complaint, the most likely diagnosis with rationale, differential diagnoses, and conditions that have been ruled out with history, physical exam findings, and/or diagnostic test results. Some choose to group the assessment and plan (A/P) together.
PLAN: can include treatment recommendations and plan, informed consent discussion if applicable, patient education, procedural notes, patient response and outcomes, plan for monitoring, plan for follow up, return precautions, etc.
Let’s demonstrate with a case: you’re seeing a 50-year-old male presenting with an itchy rash. All information is made up and serves as an example of a clinician going through the history, physical exam, differential diagnoses and plan.
S
Chief complaint: 50-year-old male with itchy rash to left forearm.
History of presenting illness: Onset yesterday morning (approximately 24 hours ago), woke up and noticed an itchy rash extending from left wrist to elbow. No other affected areas. He denies any pain. He denies noticing any weeping, vesicular lesions, or purulence at any point. He points out four small, hardened lesions on his forearm right next to each other that he noticed yesterday morning.
Medical history: no past medical history.
Surgical history: no past surgical history.
Family history: non-contributory
Social history: moved to a new house with his wife 1 month ago. From Chile, moved to Canada two years ago. No children. Works full time as an auto mechanic. No change in jobs recently.
No substance use history.
Medications: None prescribed. He tried one dose of diphenhydramine over the counter last night which helped the itching. No recent antibiotic use.
No known drug allergies.
Immunizations: up to date
Review of systems: no fevers, chills, night sweats, malaise, or unintentional weight loss. No recent travel or sick contacts. He otherwise feels well without any shortness of breath, lip swelling or tongue swelling, chest pain, abdominal pain, or diarrhea. He denies any previous allergic reactions. No recent illness. No known sick contacts. He denies using any new fragrances, cosmetic products, cleaning products, or new clothes. He has no pets and denies any bites or trauma recently. He says he’s noticed a few small spiders in the new home. No previous history of rash.
O
Non-toxic appearing, alert and oriented
BP: 125/77
HR: 75, regular on palpation
O2 sat: 97% on room air
RR: 20, regular
Temp: 37.5 C (99.5 F) oral
Derm: full skin exam performed. Noted to have a confluent erythematous area on the left forearm, markedly warm and swollen compared to the right forearm. Blanches under pressure. No vesicular lesions, papules or macules, and fluctuant areas. Not painful to the touch. The erythema extends without distinct borders from the left wrist to the left elbow, encircling majority of the forearm. There are 4, raised, firm, nodules approximately 3x3mm and 2mm in depth near the wrist. No ulceration or skin peeling. A picture was uploaded to the EMR with patient consent, comparing the L with R forearm.
A/P:
50 year old male presenting with a 24 hour history of erythematous, swollen, itchy rash to left forearm.
Most likely diagnosis: Allergic reaction to ?suspected insect bite – itchy, erythematous, swollen area with suspected bite marks. Moved to a new home and reports having seen spiders. Pruritus responded to antihistamine. Woke up with the itchy left forearm. Not painful. No systemic symptoms.
DDx (differential):
Cellulitis: less likely as not painful, but given the extension of erythema, swarmth and swelling, possible cellulitis. No known skin trauma.
Contact dermatitis: no known allergic contacts (no recent travel, camping, hiking), no new products. No vesicles or blistering appearance of the rash.
Discussed differential diagnoses and treatment options. Trial antihistamine daily plus a 5 day course of cephalexin given possibility of cellulitis. Education provided on treatment side effects and expected improvement (24-48 hours). Side effects/risks of medications reviewed. Return precautions given including spreading erythema, swelling, purulence, pain, fevers, chills, or general malaise.
He agreed with the plan.
BOTTOM LINE
Try using charting templates using the SOAP structure.
SOAP provides a concise summary of the patient encounter including our diagnostic reasoning process and plan.
It’s an excellent communication tool between healthcare team members.
As you can see – anyone reading the documentation will clearly understand the diagnostic reasoning process and plan moving forward. A colleague reading a clearly documented encounter will be thankful if they have to provide follow up (it’s a bonus if a picture is included in the documentation for skin presentations!)
I’ve made several SOAP charting templates on episodic encounters, preventive care topics, and chronic disease management visits. It’s not fool proof, but it saves a lot of time during busy clinic days. Here’s an example of my rash template.
References
Strategies for Improving Documentation [Internet]. Healthcare Insurance Reciprocal of Canada; 2017. Available from https://www.hiroc.com/system/files/resource/files/2018-10/Documentation-Guide-2017.pdf
Documentation, Revised 2008 [Internet]. College of Nurses of Ontario; 2008. Available from https://www.cno.org/globalassets/docs/prac/41001_documentation.pdf
Demsash AW, Kassie SY, Dubale AT, Chereka AA, Ngusie HS, Hunde MK, Emanu MD, Shibabaw AA, Walle AD. Health professionals' routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study. BMJ Health Care Inform. 2023 Feb;30(1):e100699. doi: 10.1136/bmjhci-2022-100699. PMID: 36796855; PMCID: PMC9936289.
ANA’s Principles for Nursing Documentation [Internet]. American nurses association; 2010. Available from http://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf
Rule A, Hribar MR. Frequent but fragmented: use of note templates to document outpatient visits at an academic health center. J Am Med Inform Assoc. 2021 Dec 28;29(1):137-141. doi: 10.1093/jamia/ocab230. PMID: 34664655; PMCID: PMC8714279.
Podder V, Lew V, Ghassemzadeh S. SOAP Notes. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482263/