What's the difference between a progress report and a SOAP note?

This is my experience. Documentation has changed over the years and is different in various locales. Early on there were Progress Notes for physicians and Nurses Notes for nurses. When I started nursing, we documented our narrative in the Nurses Notes. Physicians used the Progress Notes and used SOAP/IE format. Nurses charted SOAP notes in the Progress Notes when there was a very specific problem. I'm very partial to SOAP/IE notes.

A SOAP note might look something like this.

Problem: PAIN.

S: "My left knee hurts today."

O: Left knee, swollen, tender to touch... Walked around the unit for 30 minutes with steady gait this morning.

A: Your assessment

P: Your plan.

Later you would come back and document the evaluation. I'm guessing that SOAP/IE notes would be good for documenting nursing diagnoses, but today institutions may be other ways to do that.

On the other hand, a narrative is a chronological detailing of assessments and patient events, including the mundane ones. Lets say your shift starts at 0700. You may begin by documenting a head to toe assessment. Your narrative charting may resemble something like this.

Neuro: Mental status, neuro check, etc.

Cardiac: EKG rhythm, heart sounds, skin color and warmth, pulses, etc.

Respiratory: Lung sounds, breathing patterns, etc.

GI:

GU:

etc., etc.:

You would document the subjective findings in the corresponding system section.

At 0830, you patient may be finished with breakfast. You would document what/how much the patient ate and how well it was tolerated.

Then a family member might visit at 0930 and you would document that and how well the patient tolerated it.

etc. etc.

Some hospitals eliminated Nurses Notes and so nurses documented their narrative in the Progress Notes. I remember some physicians were not happy about that. Traditional narrative gives many nurses a sense of security - and I do remember one nurse who swore it was her narrative documentation that saved her during a law suit.

Now nurses also utilize checklists, flowsheets, pathways, charting by exception and electronic medical records. Many nurses still do the narrative in addition to the other required documentation tools. Hope this helps. Others may have a different take on this.

Thanks saillady for your thorough and helpful response. Much appreciated:wink2:!

Hi Daytonite!

For my project, I'm going to be including anecdotes from real life cases, and I saw one of your former posts (see below). This is perfect for what I'm doing. Would it be alright if I included this passage verbatim? I can give you a credit in my acknowledgement section, if you like. Or, I can have my publisher contact you to do a formal permission request (in the new year), if you would like.

I can't send private emails on this forum, so please email me privately to discuss further...

"At one of the legal seminars I attended we were shown a 15-minute video of a nurse being questioned by an attorney. It was awful as the attorney pointed out all the things the nurse didn't do or chart what she had done. The lawyer made the nurse look incompetent. And all he did was act polite and ask nice questions that were designed to bring out the flaws in her documentation that he wanted the jury to hear. On top of that he had a huge blow up of her actual page of nurses notes for the jury to see. They were sloppy and there were several places where she had scratched out the information she had written (wrong way to correct a document)."

Hi Daytonite....

Thanks for the private message. You may be right re: the public domain. I just feel unethical using a whole paragraph that someone else has written without acknowledging them in any way. And, I would want to use your paragraph verbatim, as it says exactly what I wish to express in that section of my report. I emailed my publisher today and asked her: re the policy on stuff in the public domain, so I'll wait to hear back from her. If there is no violation in using your excerpt, would you like me to include your name, a pseudonym or just indicate the author as anonymous? In any event, I'll write you and let you know what the developmental editor says re: public domain.

Thanks, as always. And, please send a private message when responding to my above question.

You are so TREMENDOUSLY helpful, Daytonite, and thanks a million for your last private message. I can't tell you how grateful I am for your amazing feedback. I still have not heard back from my source re: the public domain, but I did some research on my own and from what I can tell, I should be able to use the excerpt. As its verbatim, as a courtesy, I'll probably mention something about allnurses.com. I won't provide a name under the excerpt, as requested, probably just a caption like "RPN (hospital)". If you want to hear more about my project, send me an email address as I can't send private messages from this forum, yet. Otherwise,I'm sure I'll run into you again on this forum!

Hi Daytonite...

Remember me? The permissions department just contacted me and it seems that I do require permission, after all, to use something from an online forum. If you are still okay with me using your quote (as referenced earlier), do you have an email address that you can give me so the permissions department can contact you? It's my first book, so I'm not exactly sure about the procedure, but I imagine they would contact you to make sure I did, indeed, secure permission from you. I will, of course, use a pseudonym as the author of your excerpt, as requested. The Permissions Dept. would most likely contact you next year some time, so I would need to have an email address that you know will be active for awhile.

Let me know your thoughts.