Get It Write

Summary

Aim

To improve the quality of nursing clinical documentation used by the JH&FMHN , to 50% by December 2015.

Benefits

• Improves the quality of nursing progress notes.
• Reduces adverse events caused by poor clinical documentation.
• Improves communication and handover processes with other members of the multidisciplinary team.
• Improves patient care through accurate and timely clinical documentation.

Background

For more than a decade, root cause analysis investigations and NSW Coroner’s inquests have noted concerns with the quality and content of clinical documentation by nursing staff in the JH&FMHN . Previous activities to address these concerns and improve the quality of clinical documentation have included a statewide education program led by the governance unit and a mandated health record audit. These approaches did not improve the quality of documentation, or reduce the number of recommendations for improvement.

Implementation

• A literature review was undertaken to assess the benefits of a range of clinical documentation models.
• Stakeholder feedback and consultation was undertaken within working party focus meetings.
• The SOAP methodology was selected as a prescriptive documentation style for use in all nursing progress notes. The SOAP methodology addresses the essential elements of quality documentation, to deliver a structured, accurate and complete account of patient care provided.
• SOAP methodology information cards were developed for staff, for easy reference while completing nursing progress notes.
• An audit tool was developed, to identify where the SOAP methodology was present in nursing progress notes.
• An audit of nursing progress notes was conducted with 30 health records from Cooma Correctional Centre and Long Bay Hospital.
• Education sessions were provided to all nursing staff at Cooma Correctional Centre and Long Bay Hospital.
• Implementation audits were completed prior to and following staff education sessions, to evaluate awareness and understanding of the SOAP methodology in clinical practice.
• A process was developed, so clinical documentation can be reviewed during the performance appraisal process (currently pending executive approval).

Project status

• Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

• Project start: 1 July 2015
• Project finish: 2 December 2015

Implementation sites

• Cooma Correctional Centre Health Centre
• Long Bay Hospital

Partnerships

• Clinical Leadership Program

Results

• Prior to the project, staff were unaware or had little awareness of the SOAP methodology and its application.
• The SOAP methodology has improved the standard of clinical documentation in the nursing progress notes, by addressing essential elements of patient care delivered by staff.
• The post-education audit found there was a 59% improvement in the quality of clinical documentation.
• The SOAP methodology has been mandated by the network as the approved method of documentation for clinical entries requiring assessment or intervention.
• All nursing staff are now provided with information cards on lanyards.
• Education on SOAP methodology is provided in the orientation program for all new clinical nurse educators, via the Health Education and Training Institute (HETI) online training.
• Failure to meet the mandated medico-legal requirements of documentation covered in HETI online training, will be managed at an individual clinician level under the performance management framework.
• The project team is seeking executive support to implement SOAP across NSW .

Lessons learnt

• We found that once a couple of staff started to use the SOAP methodology in their clinical documentation, it increased the likelihood that others would follow, which resulted in better documentation standards.
• We found that the SOAP methodology is only suitable for patient interactions where an assessment or action is required. There are situations were a single line entry is appropriate and SOAP is not required.

Further reading

• NSW Health Government. Health Care Records: Documentation and Management [Internet]. 2012 [cited 24 September 2015].
• EMR Consulting Services. FAQ: SOAP notes [Internet]. 2010 [cited 24 September 2015].
• Cameron S, Turtle-Song I. Clinic Procedures [Internet]. 2002 [cited 24 September 2015].
• Mootz R. Maximizing the effectiveness and efficiency of clinical documentation [Internet]. 2012 [cited 24 September 2015].
• Weed L. Medical records that guide and teach. New England Journal of Medicine 1968; 278(11): 593-600.
• Whitehead S. The EMT Spot [Internet]. 2009 [cited 24 September 2015].

Project team

• Bernadette Hollis
• Jonathan Lapitan
• Rebecca Lucas
• Lee Trevethan

Contact

Jonathan Lapitan
Clinical Nurse Educator
Justice Health & Forensic Mental Health Network
Phone: 02 9700 3274
Jonathan.lapitan@justicehealth.nsw.gov.au