Good Essay On Nursing Documentation

Nursing documentation plays a big role towards not only achieving efficiency in management of patients, but also assisting in accurate decision making among the nursing staff. Among the most common methods of documentation practiced around the world include SOAP/SOAPIER and focus charting. Both of these documentation methods are problem-oriented where the nurse begins by identifying the problems that the patient presented with. While focus charting narrows down to the behavioral concerns of the patient such as a decreasing urinary output in a specific duration, SOAP/SOAPIER, the nurse systematically lists all the problems in a more conclusive manner. Focus charting has three components which are data, action and response. On the other hand, SOAP/SOAPIER has subjective information which highlights the symptoms, objective information highlighting the signs, assessment data, plan, implementation and finally revision (Treas & Wilkinson, 2013).

Focus charting as a method of documentation has its advantages and disadvantages. Its advantages include:

It is compatible with most uses of the nursing processes. This means that it is able to meet the necessary demands of documentation by nurses.
It saves on time by using more than one checklists by nurses. Every nurse can use their own check list without having to look at those created by other nurses since it is updated regularly.

Its shortcomings include:

It is unable to chart while adhering to the nursing diagnoses as well as the expected outcomes.
It does not offer solutions in the event that the problems of patients are missed due to insufficient database.
On the other hand, the advantages of SOAP/SOAPIER include:
It is able to provide for the continuity of communication and care by keeping all the necessary information in one place (Marrelli & Harper, 2000).

It reinforces the use of the nursing process by enhancing the process of decision making.

Among its disadvantages are:
Inability to track the trends in the status of the patient.
It may result in a loss of chronology of charting because more number of sheets are required.
Focus charting and SOAP/SOAPIER can be used interchangeably depending on the facility. This is because both serve as adjunct to document the routine, observations and other assessments of a patient.

References

Marrelli, T. M., & Harper, D. S. (2000). Nursing documentation handbook. St. Louis: Mosby.
Treas, L. S., & Wilkinson, J. M. (2013). Basic nursing : concepts, skills, & reasoning. Philadelphia: F.A. Davis.