I work at a doctors office where they use electronic SOAP notes. When I was hired, I was told the nurse was responsible for the Subjective and Medication note. Now they want me to do the whole note. I am uncomfortable writing the Objective, Assessment, and Plan portion isnt that the physician or nurse practitioners place?
Nancy Brent replies:
Documentation in the medical record using a SOAP format is one of many formats that can be used to document nursing notes and interventions, whether using an electronic format or using hand written nursing notes. As you are aware, a nurse is always able to document a patients subjective complaints or concerns, document the objective conduct of the patient observed by the nurse, perform and document a nursing assessment of the patient, and develop and document a nursing plan of care.
Indeed, this approach mirrors the nursing process, which includes the assessment of the patient, the planning of care, intervention, and the evaluation of the overall process. Because the SOAP format does not include the evaluation portion of the nursing process, some facilities use an expanded SOAP format to include the evaluation aspect of the nursing process.
The specific position in the office in which you work was not included in your question. Whatever your role, your SOAP documentation would be specific to that role vis-à-vis the patient. Others in the office, such as the nurse practitioner or the physician, would document their own notes and SOAP components unless you are acting as a scribe and document what they have decided are the identified problems, document their assessment, and then document the plan of care identified by them for the particular patient. Note that you will need to follow established requirements for documenting as a scribe, such as identifying your role in the record.
You might want to read more about SOAP documentation. There is a wealth of information on the Internet and in texts and articles on nursing documentation. Many of these resources incorporate the SOAP format in electronic documentation as well.
Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.