Journal of Research Development in Nursing and Midwifery (Oct 2023)
The effect of the SOAPIE nursing notes method on the quality of nursing documentation
Abstract
Background: Nursing notes are among the most critical tasks for nurses, and not performing it in a correct manner will lead nurses to face numerous issues and problems. Nursing notes can be written in a variety of ways. One approach is the nursing process-based SOAPIE (Subjective, Objective, Assessment, Plan, Intervention, Evaluation) method. Thus, the present research was conducted to determine of the SOAPIE Nursing note Method on the quality of Nursing Documentation. Methods: The present semi-experimental study was conducted in 2021 at Yasuj hospitals, in Iran. The samples consisted of 120 nurses selected through the convenience sampling method based on the inclusion criteria. The samples were assigned to two intervention and control groups through a random allocation method. Nursing notes using the SOAPIE method was implemented for 3 weeks in the intervention group after obtaining informed consent. The data were collected using the checklist of nursing documentation principles, which involved two sections of demographic information and nursing documentation-related items before the intervention and one month after the intervention. The mean score of each of the eleven principles was determined from the total score of 100. Three levels were considered in the tool’s scoring: Poor (0-33), moderate (34-66), and favorable (67-100). The descriptive and inferential statistics methods (the chi-square test, independent t-test, and paired t-test) and SPSS software version 21 were used for data analysis. Results: The total score of quality of nursing documentation had no statistically significant difference in the intervention and control groups before the intervention (P<0.05). However, one month after the intervention, the total score of the quality of nursing documentation showed a statistically significant difference between the intervention and control groups (P=0.001). Before the intervention, the mean total scores of the quality of nursing documentation were 46.66±14.45 and 48.22±12.45 between the two intervention and control groups, respectively, and one month after the intervention, they were 91.53±5.98 and 48.52±12.61, respectively. Conclusion: According to the results of this study, nursing notes using the SOAPIE method lead to promoting the quality of nursing documentation. Nursing documentation based on the high quality of nursing notes should always be taken into account. It is suggested that the findings of this study be employed for educational and research planning in nursing.
