SOAPIE notes

[Huganurse]

Just curious, does anyone still use this form of charting? I used to love it, like putting a puzzle together. It is also very focused and complete. But, I'm glad I don't have to use it these days since I absolutly do not have the time! Too many patients, too little time.

[Mijourney]

Hi Huganurse. When I worked in the hospital setting, I saw a few doctors and especially residents use the SOAPIE format. You're right that it is time intensive. You're also right that this format is one of the best in keeping care focused. The physician that pushed this format forward some decades ago knew this but had quality on his mind and was hoping that as staff learned to use it and grew to respect it, that patient care and outcomes would considerably benefit from clear, concise written communication. As you point out, unfortunately you do not have time for SOAPIE notes.

I'm going to assume that your facility does not document on EMR (electronic medical records)? I believe that as the full implementation of rules and regs related to HIPAA get closer that you may find that your documentation requirements will become more standardized.