The SOAP note and the PIE charting as methods of medical documentation

Documentation of information is vital in medical practice, regardless of cadre of professionals. Accurate documentation plays a pivotal role in provision of health services. Clear and accurate documentation is necessary for safe and evidence-based nursing practices (Asmirajanti et al., 2019). Nurses across all positions starting from bedside nurses to administrative nurses carry out documentation. It is therefore important that nurses come up with creative ways of ensuring adequate documentation is done within hospitals. The SOAP note and the PIE charting are examples of methods of documentation that have been adopted by healthcare organizations to help summarize information in a clear and concise manner. 

Documentation is essential in communicating the problems of patients and any interventions carried out (Siegrist et al., 1985). The common saying in medicine is “if it is not documented, it was never done”. This means that while an intervention may have been made, if not documented, it means that the intervention was not provided. Nursing documentation is important in communicating patient progress to other nurses and physicians. In addition, nursing documentation provides a basis for demonstration of nurses’ contribution to patient care. When nurses document interventions they have undertaken, it informs decision-makers of the key role nurses practice within healthcare organizations. 

The SOAP note is a method of charting that contains four components: Subjective, objective, assessment and plan. It was suggested by Lawrence Weed about 50 years ago when he suggested a system that would comprehensively capture patient data in an organized manner (Villemaire &Oberg, 2005). It is a good reminder of specific tasks to healthcare workers, ensuring that all vital information is captured in the note. The SOAP note provides a way for healthcare workers to document information in an organized manner. S in SOAP stands for subjective, which is the personal report of a patient or caretaker regarding their condition. It contains information usually contained in the chief complaint, history of presenting illness, review of systems and current medications and allergies. 

O stands for objective which contains objective data collected from interaction with the patient. It contains findings from physical examination, laboratory data, imaging results and a summary of information from other physicians (Podder, 2020). A stands for assessment, which is a combination of the objective and subjective information collected in the previous sections. It involves ad assessment of the patient’s general condition based on the presenting problems. The outcome of this section is a generation of a problem and differential diagnosis starting from the most likely to the least likely (Podder, 2020). The plan section details a necessary interventions, investigations or consultations with other clinicians to better the patient’s situation. The SOAP not ought to involve all the information collected in narrowing down problems and providing solutions for them. 

The SOAP Note is an important tool for nursing as it helps capture a patient’s information and hence necessary for communication to other patient caretakers. The note provides a standardized format organizing patient information for better organized patient care (Buchanan, 2017). Any nurse or physician can read the note and understand a patient’s condition and progress, making it easy to plan the next steps in management. While the note is important for patient management, it is also important in legal matters. A well written SOAP note helps prevent any undesirable outcomes that result from incomplete or inaccurate documentation of a patient’s information. 

While the SOAP not helps in facilitating succinct medical communication, it lacks the flexibility to document several change over time. An important weakness is that it does not incorporate the element of time into the information, failing to accommodate the changing dynamics in patient diagnosis and management (Podder, 2020). Another weakness is the need for flexibility in the order of information, which could be time-consuming. Sometimes, the information overlaps and is entered repeatedly. This can lead to the plan of care being copied from one patient to another without consideration of individual needs. Hence, there is need for adoption of flexibility and the inclusion of the element of time in the SOAP note. 

The PIE (Problem, intervention, evaluation) charting system was introduced in 1984 (Villemaire &Oberg, 2005). The PIE method of charting is often regarded as a process-oriented method of charting used in nursing. This simplified approach of documentation focuses on the patient’s problem, intervention and evaluation. This system of charting does not include the plan of care for a patient. This system of charting allows the identification of problems during every shift. In addition, it incorporates the use of patient progress notes and flow sheets which often does not include the patient plan of care (Siegrist et al., 1985). This type of charting allows for evaluation of a problem several times and the evaluation of different problems and interventions at the same time. 

This type of charting system is essential in communicating a patient’s condition to other healthcare providers taking part in patient management. With the incorporation of time and continued evaluation, it is easy to determine a patient’s progress based on the PIE chart. A constant update of a patient’s problems means provides a basis for early consultation and intervention in serious medical situations. In addition, it provides a basis from which other nurses can fully understand a patient and individualize care based on the problems and interventions documented over time. This system of charting is important as a way of orienting young nurses in patient care since they can do continuous updates on patients’ condition. 

The PIE system of charting has the disadvantage of excluding patient plan of care. This means that continuity of information and planned intervention is sometimes hindered. Nurses and physicians have to depend on other documentations or other charts to determine previous plans of care in order to make further plans. While this is time-consuming, it may pose a challenge for nurses who have limited experience (Siegrist et al., 1985). The nurses may incorporate different approaches to patient care, leading to inconsistencies in provision of care. Hence, PIE charting needs adequate orientation before use and needs to be accompanies by documented plans of care. While this can be done through the use of other charts, the PIE charting system can be revised to provide for the inclusion of a plan of care. This way, all information is consolidated to communicate patient information effectively. 

SOAP NOTE 

PIE CHARTING 

PROBLEM 

Faith Paul is a 3-day old neonate, born via spontaneous vertex delivery. Mother reports that the neonate has been refusing to breastfeed since a day after birth. The neonate has been crying constantly and is not soothed by rocking. Also, there was an associated hotness of body this morning. The mother has tried to provide formula but baby is still not taking. Therefore, the baby has not fed on anything for about 24 hours and mother reports that the baby’s skin appears dry. Baby had decreased urine output and has not passed stool for two days. Mother reports that she had a urinary tract infection just before the birth of the baby and did not receive any medical intervention for it. She, however, denies any unusual events during delivery. 

INTERVENTION 

Take temperature, pulse oximetry and weight. Carry out lab investigations: Erythrocyte sedimentation rate, complete blood count, blood culture and CRP. Expose the child and insert and intravenous line. Administer IV fluids: ringer’s lactate and dextrose as per baby’s weight. Start IV penicillin at recommended dosage. Administer acetaminophen to lower temperature. Fix nasogastric tube and encourage mother to express breast milk according to the child’s requirements as per the weight. Teach mother to administer breast- milk via tube 3-hourly. Allow for burping before putting the baby down to prevent aspiration. Monitor bowel movement and urine output every three hours and record in input-output chart. 

EVALUATION 

Patient is responding well to interventions. Temperature is lowered and mother reports that hotness of body has decreased. The baby is alert, active and reacting to surroundings. Primitive reflexes are normal as per baby’s age. Baby’s skin and mucous membranes appear well-hydrated with a flat anterior fontanel. The baby’s feeding has also improved but is still on nasogastric tube feeding and tolerating well. No aspiration reported so far. Mother has sufficient breast milk as per the baby’s needs. Baby has voided urine twice and has had one bowel movement. Lab investigations show a raised CRP, ESR and white blood cell count. All other cell lines are within normal ranges. 

References 

Asmirajanti, M., Hamid, A. Y. S., & Hariyati, R. T. S. (2019). Nursing care activities based on documentation. BMC nursing , 18 (1), 1-5. 

Buchanan, J. (2017). Accelerating the benefits of the problem oriented medical record. Applied Clinical Informatics , 26 (01), 180-190. 

Kerr, S. D. (1992). A comparison of four nursing documentation systems. Journal of nursing staff development: JNSD , 8 (1), 27-31. 

Podder V, Lew V, Ghassemzadeh S. SOAP Notes. [Updated 2020 Apr 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482263/ 

Siegrist, L. M., Dettor, R. E., & Stocks, B. (1985). The PIE system: complete planning and documentation of nursing care. QRB. Quality Review Bulletin , 11 (6), 186-189. 

Villemaire, L., Oberg, D., & Villemaire, D. (2005). Grammar and writing skills for the health professional . Nelson Education.