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US Health and Healthcare Current State: Nurse Executives
Published in Connie White Delaney, Charlotte A. Weaver, Joyce Sensmeier, Lisiane Pruinelli, Patrick Weber, Deborah Trautman, Kedar Mate, Howard Catton, Nursing and Informatics for the 21st Century – Embracing a Digital World, 3rd Edition, Book 1, 2022
Robyn Begley, Laura Reed, Julibeth Lauren
Nursing documentation history is rich and dates back to the Crimean War with Florence Nightingale (1820–1910), the social reformer, statistician and renowned founder of nursing practice and the documentation of her findings, experience, perceptions and evidence to support recommended changes in practice (American Nursing History, n.d.). The patient's medical record began taking shape as each discipline documented in their own section, with a section specifically dedicated to medical orders and to a chart tracking of patient vital signs, which later became flowsheets. Over many decades, nursing notes progressed from end of shift summary notes, using black, blue or red ink, depending on your designated shift assignment, to highly complex and sophisticated assessments reflecting the nurses' critical thinking in assessments, interventions, planning and evaluation of patient outcomes in the form of SOAP (Subjective, Objective, Assessment and Plan) notes (circa 1968). Adapted from physician colleagues, SOAP notes were one of the very first templates nurses used to guide communication of patient care within and across disciplines.
Teaching Medical Students to Write Proper Clinical Notes Using Expectancy-Value Theory
Published in Michael J. Madson, Teaching Writing in the Health Professions, 2021
Also important in our teaching is keeping the focus on the patient, and with time, helping students create notes that are easier to read and comprehend.18 To guide students, we utilize the SOAP note template (see Appendix 1), which is commonly utilized in medicine and allied health. The SOAP note was developed by Dr. Lawrence Weed, professor of medicine and pharmacology at Yale University.19,20
Developing Pediatric Programming in a Private Occupational Therapy Practice
Published in Florence S. Cromwell, Private Practice in Occupational Therapy, 2013
Daily notes summarize each treatment session and might be written in one of the following ways: A narrative format.A narrative format which is highlighted in the margins. The highlighting is to alert the reader/therapist to specific areas of interest and is helpful in reviewing daily notes when writing formal progress reports. Examples of highlighting may include: praxis, sensory processing, organization of behavior, social and emotional behaviors and communication.The Subjective, Objective, Assessment, Plan (SOAP) note format.
The recent evolution of patient care rounds in pediatric teaching hospitals in the United States and Canada
Published in Hospital Practice, 2021
Jeffrey Van Blarcom, Andrew Chevalier, Benjamin Drum, Sarah Eyberg, Elizabeth Vukin, Brian Good
In 2014, the I-PASS study group focused their attention on rounding, seeking to improve another area of communication vulnerability during a patient’s day. They recognized that the presence of physicians, advanced care providers, nurses, families and the patient during FCR presented an opportunity for the application of the I-PASS communication structure and its associated benefits. The group invited nurse leaders and family members from the original study sites as well as national health literacy experts to co-produce an FCR model that met everyone’s needs. The rounding model they created, known as the ‘Patient- and Family- Centered I-PASS Rounding Model’ (PFC I-PASS) [40], encourages communication and the active participation of nurses, families and the provider team. After the introduction of medical personnel, the new communication structure involves a request for the family’s input first, which starts a conversation about the child’s current state and the family’s concerns. This is followed by a request for the nurse’s input, a novel approach which emphasizes the importance of the nurse in caring for the child. The team thereafter completes a succinct patient summary and assessment in plain language that is understandable to the family, followed by the other elements of the I-PASS structure, which takes the place of the standard SOAP note presentation format. To ensure that the family is engaged and understands the plan for the day, the team asks the family to verbally summarize the plan. This last step is vital in ensuring understanding between all parties.
The OTA'S Guide to Documentation: Writing SOAP Notes (4th Edition) 2017
Published in Occupational Therapy In Health Care, 2018
Utilizing a scaffolding approach to learning, the manual takes the occupational therapy assistant student on a journey through the documentation process that is both logical and unintimidating. Chapter 1 re-enforces the use of professional language, with an emphasis on the International Classification of Functioning, Disability and Health (ICH) and OTPF-3 language. This chapter also provides an important discussion on how occupational therapy is different from other health professions. Chapters 2 and 3 explain the health record and billing and reimbursement. Chapters 4 through 5 focus on the use of professional terminology and avoiding common documentation mistakes. Chapters 6 through 10 explain the SOAP note, with an individual chapter focusing each part of the note with examples. Chapters 11 through 13 discuss documentation in various contexts, improving observational skills, and improving note writing. At the end of each chapter, there are numerous worksheets for students to complete in order to review the material.
Implementation of free water protocols in acute care: An observation of practice
Published in International Journal of Speech-Language Pathology, 2022
Joanne Murray, Chelsea Walker, Sebastian Doeltgen
In terms of documentation, we have our SOAP notes, we write in there what we did and our recommendations so it’s very clear.[…] We also write it on their communication board in the patient’s room, and then also in their bedside folder as well (SLP3).