Tips for Teaching Effective Documentation

One of the most important aspects of the clinical experience for students is, learning how to properly document patient encounters. Clinical documentation is written in a specific format to minimize confusion and reduce opportunities for the misinterpretation of patient conditions and treatment plans. This information is essential for the transference of information between doctors, nurses, and staff. Information transference between rounds stays or visits promotes the continuity of care, billing, and payment from insurance companies alongside Medicare/Medicaid, and liability protection.

The following strategies are ways to assist learners in SOAP note documentation. They are tailored to fit the demanding schedule of a busy provider.

Use Your Documentation to Teach

Use the documentation you already have to produce a teaching tool. If your practice allows grant beginning students, read-only access to your SOAP notes so the student can see firsthand what proper documentation looks like. The tool asks the student to review your notes and tell you what s/he notices about your documentation.

When the student begins to document cases on his or her own, have the student compare his or her SOAP notes to your notes from similar cases.

Scribe and Teach Simultaneously

As you are documenting, explain why you document the way you do. Be sure to point out the following best practices:

• Write SOAP notes promptly, meaning soon after meeting with the patient, but not in front of the patient. You may need to take personal notes while on the appointment. However, actual SOAP notes should be documented after you have left the patient.
• Use a professional voice and tone when writing medical documentation. Remind the student that these notes may be viewed by another professional or even used in a court case.
• Be concise, yet thorough.
• Document symptoms and details about the patient, using respectful language. Again, remind the student that other health professionals may view these notes in the future.
• Document evidence for judgments and decisions.
• Be specific, especially when documenting potentially confusing information.

Use an Attestation as a Learning Tool

If your clinic uses an attestation as part of the practice, use this opportunity to evaluate the quality of the student’s documentation. Make corrections and explain why changes are necessary.

Your Role in Teaching Clinical Documentation

Nurse practitioner students in their first clinical rotation have a foundational knowledge of SOAP notes writing. It is your role to improve the quality of documentation. Students in their residency program are more astute in their SOAP note writing skills. However, they may still need some guidance.

As a result of your efforts, patients will receive better care and your colleagues will be able to interpret clinician notes with greater ease.