Documenting the patient’s history, the ailment, diagnosis and the course of treatment is one of the primary responsibilities of a certified nursing assistant or CNA, under the guidance of the registered nurse.
In addition to following the universal guidelines with regard to documentation of the basic records of the patient during his or her stay in the hospital for treatment, depending upon the policies of the hospital or the nursing home, the management might prescribe some typical charting format to be followed by the CNA for documenting the patient’s health history. One of the forms of charting is called as SOAP Charting.
What is SOAP Charting?
SOAP charting is the abbreviated form for Subjective, Objective, Analysis, and Plan.
Subjective: The CNA makes note of all the details provided by the patient in connection with his or her suffering or ailment, under this heading. In addition to details provided by the patient, the details provided by other family members can also be included under this heading.
Objective: Under this heading, the CNA should record all the details she or he has observed during the course of analysis of the patient. It has to be ensured that what has been actually observed only should be entered. The opinion of the CNA should not be a part of the objective analysis.
Analysis: Under this heading, the CNA can record It is here that the CNA gets the opportunity to express his or her analysis of the patient’s condition, using the nursing diagnoses.
Plan: Under the column, the CNA should record all the actions done so far and also the proposed plan of action, taking guidance from the registered nurse. The plan should also include details of responsibility for each type of action as to who will execute the same and when and how it will be executed. Effective usage of this part of the charting will result in better organization of the patient’s care and well being.