First Encounter in the SOAP note arena

Compare the documentation (SOAP note) used by Nurse Practitioner (NP) to the current
way you use nursing documentation and answer the questions below:
a. How is the documentation different when comparing NP to nursing documentation?
b. How is the documentation similar when comparing NP to RN?
c. What areas do you view as challenging in the SOAP note? Explain.
d. What steps can you implement to overcome these challenges?
All references used cannot be older the 5 years old.

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

FIRST ENCOUNTER IN THE SOAP NOTE ARENA 2
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.
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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