Implementing an Education Programme and SOAP Notes Framework to Improve Nursing Documentation
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Aim: The aim of the project was to introduce an education programme for the nursing profession which would increase adherence to The Nursing and Midwifery Board of Ireland (NMBI) documentation standards. This was to be achieved through the delivery of six unique education sessions, and the introduction of the SOAP (subjective, objective, assesment and plan) Notes Framework for documentation.
Rationale: Following the reviews of three adverse events the key areas of concern included the occurrence of a failure on behalf of the nursing profession to communicate essential information to the greater multidisciplinary team following client interactions. furthermore, the absence of a standardised approach to the formation of the nursing professions clinical entries allowed for misinterpretation of clients mental state and wellbeing.
Change Process: The HSE Change Model was used to guide the change. Monthly education sessions with facilitated over a six-month period. Focus groups and consultation with key stakeholders such as the State Claims Agency assisted the process.
Evaluation: The education programme was evaluated using Kirkpatrick's (1959) evaluation Model. the overall initiative was evaluated using an audit tool based on NMBI documentation standards via pre and post intervention auditing of clinical records.
Results & Conclusion: The results showed a 56% improvement in adherence to NMBI documentation standards following the introduction of the education programme and SOAP Notes Framework. The initiative supports good systems of clinical governance and quality assurance in order to assist in the prevention of similar adverse events and hence ensure positive experiences and outcomes for future service users.