Standardizing SOAP Note Documentation throughout a FNP Program

SOAP notes provide structure for clinicians to gather information on the patient’s history and examination, culminating in an informed assessment and plan. Teaching advanced practice nurses an organized method to gather and document patient information can be challenging due to the lack of standardization in nursing education. Leading advanced health assessment textbooks format the documentation of patient history and physical examination differently. Moreover, in advanced nursing programs, faculty have the power to select text books and SOAP note format from one course to the next. This leaves the possibility of a lack of continuity for students. It was for this reason that the decision to implement a streamlined process of SOAP note writing was made for student and faculty benefit.
The purpose of this innovative activity and exploratory pilot research was three-fold:
(1) To implement an innovative streamlined SOAP note documentation process in a FNP program.
(2) To explore faculty perspectives related to implementation of streamlining SOAP notes in a FNP program
(3) To develop a deliverable education session focused on enabling the learner to analyze, appraise, and replicate outcomes of standardizing SOAP note formats in a FNP program.

Standardizing SOAP Note Documentation throughout a FNP Program Presentation