What Forms Can I Use to Teach a Class on Nursing Documentation?

Nursing documentation follows the "SOAPIE" method of recording patient condition and nursing activity. "S" means "subjective data" or the patient's chief complaint. "O" means the objective data that you can measure or observe. "A" is for "assessment," or the conclusions based upon both subjective and objective data. "P" is the plan of treatment. "I" stands for the interventions you conduct toward the treatment plan, and "E" is an evaluation of the effectiveness of your nursing activity.



Most standard forms do not require complete SOAPIE documentation. However, teaching the SOAPIE style is the most effective way to help students focus on what is important to document.

Admission H&P

• A general Admission History and Physical Examination form requires a nurse to record a great deal of subjective history and information as reported by the patient and/or his family. The review of systems teaches the student to elicit medical history details and determine which are important to the current complaint. The student also records the obvious, such as a productive cough or poor peripheral circulation. Following the concentration on the "S" and "O" aspects of documentation, the student also learns of "I," or interventions already in place, such as the current medication list or therapies the patient is undergoing.

Nursing Care Plan

• The Nursing Care Plan is a working document, first established upon admission and modified as necessary throughout the patient's hospital stay. Based upon the Admission H&P, the student will make several Nursing Diagnoses and related care plan interventions to address each diagnosis. The nursing diagnoses constitute the "A," or assessment portion of nursing documentation, while the related care plan interventions serve as both "P," plan, and "I," interventions. Nursing care plans are modified as patient needs change. As a diagnosis is noted as resolved, the student demonstrates "E," or evaluation of the nursing process.

Incident Reports

• Incident Reports are completed when any untoward or unexpected event occurs, such as an accident, mistake in treatment or death. Incident Reports are not part of the patient's medical record, but the information required to complete them leans heavily on some aspects of the SOAPIE form of documentation, particularly the objective "O" aspect. Subjective documentation, "S", may be used to demonstrate the patient's state of mind or disorientation, for instance, but assessments, "A," and "P" are usually absent. Interventions, "I," are documented for communication of the incident to a nursing supervisor and the attending physician and any immediate treatments to limit harm.

Nursing Notes

• Narrative nursing notes provide the best format for a full SOAPIE style demonstration of nursing documentation. After working through three challenging forms that regulate and limit the information documented --- an admission H&P, a Nursing Care Plan, and an Incident Report --- we fully appreciate a return to narrative nursing notes. Use a student nurse and patient role play interaction. Invite the rest of the class to document the exchange in the nursing notes using the SOAPIE method.