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THE PERCEPTION ON SOAPIE AND TRADITIONAL DOCUMENTATION AMONG STAFF NURSES IN SELECTED HOSPITALS
An Undergraduate Thesis Proposal Presented to The Faculty of the College of Nursing University of Perpetual Help, Laguna
In Partial Fulfillment of the Requirements for the Degree of The Bachelor of Science in Nursing
By: De Guzman, Gracielle V. Gutierrez, Alix Roxanne M. Leyva, Arrhenius S. Malabanan, Kristine Allen B. Nullas, Regen Miguel B. Resurreccion, Precious Evangelyn S.
March 2010
Chapter 1 THE PROBLEM AND ITS SETTING Introduction One of the primary purpose of a nurse is to give to the client the better if not, the best nursing care in order for the client to achieve optimum health status. On applying nursing care, every bit of nursing action must be carefully documented to provide continuity of care for the patient. Documentation in general terms is the process of providing evidence or is any communication materials (such as text, video, audio, etc., or combinations thereof) used to explain
some
attributes
of
an
object,
system
or
procedure.
Nursing
documentation clearly describes an assessment of the client’s health status, nursing interventions carried out and the impact of these interventions on client outcomes.
One type of documentation in the nursing field is the use of SOAPIE documentation which is an acronym for Subjective, Objective, Assessment, Planning, Intervention and Evaluation. If you use the SOAPIE format, you’ll document the following information for each problem: Subjective data which consist the information the patient or family members tell you, such as the chief complaint, then the Objective data which are factual, measurable data that are gathered during the assessment, such as observed signs and symptoms, vital signs, and lab test values, Assessment data which includes the conclusions based on the collected subjective and objective data and formulated
as patient problems or nursing diagnoses, It must be systematic and ongoing, And pertinent data are collected using appropriate assessment techniques. Planning which shows your strategy for relieving the patient’s problem including immediate or short term actions and long term measures. It must be individualized to the patient and patient’s condition of needs, Plan is developed with the patient, significant others, and health care providers, when appriopriate. It reflects current nursing practice and provides continuity of care.Intervention which shows the measures you’ve taken to achieve an expected outcome,It is consistent with the established plan of care and implemented in a safe and appropriate manner. Lastly, Evaluation that shows the effectiveness of your interventions.It is systematic, ongoing, and criterion based. In here the nurse evaluates the patient’s progress toward attainment of outcomes. If expected outcomes fall short, alternative interventions should be implemented. Another type of documentation used by the nurses is the traditional or classic type of documentation wherein the nurse just records everything that has been done to the patient without any organized plan or pattern. Perception in humans describes the process whereby sensory stimulation is translated into organized experience. That experience, or percept, is the joint product of the stimulation and of the process itself, thus, every person has their own unique perception in every thing or event that has happened. In this study, the researchers aim to find the perception of staff nurses on SOAPIE and traditional documentation in selected hospitals.
Theoretical Framework
In order to receive information from the environment we are equipped with sense organs example: eyes, ears, and nose. Each sense organ is part of a sensory system which receives sensory inputs and transmits sensory information to the brain. A particular problem for psychologists is to explain the process by which the physical energy received by sense organs forms the basis of perceptual experience. A major theoretical issue on which psychologists are divided is the extent to which perception relies directly on the information present in the stimulus. Some argue that perceptual processes are not direct, but depend on the perceiver's expectations and previous knowledge as well as the information available in the stimulus itself. This controversy is discussed with respect to Gibson (1966) who has proposed a direct theory of perception which is a 'bottom-up' theory, and Gregory (1970) who has proposed a constructivist (indirect) theory of perception which is a 'top-down' theory. Psychologists distinguish between two types of processes in perception: bottom-up processing and top-down processing. Bottom-up processing is also known as data-driven processing, because perception begins with the stimulus itself. Processing is carried out in one direction from the retina to the visual cortex, with each successive stage in the visual pathway carrying out ever more complex analysis of the input. Top-down processing refers to the use of contextual information in pattern recognition. For example, understanding difficult handwriting is easier when reading complete sentences than when reading single and isolated words.
This is because the meanings of the surrounding words provide a context to aid understanding. Iyer, P.W., & Camp, N.H. (1999) states that clear and consistent documentation of the care provided to patients has always played a pivotal role in validating a nurse's legal and ethical responsibilities. Today, the emphasis on increased quality of care at a lower cost places additional challenges on nurses in all settings. Not only must written communication survive the scrutiny of multiple regulatory and accrediting agencies, it must do so without contributing to excessive labor costs Conceptual Paradigm Independent Demographic Profile in terms of:
Dependent Perception on SOAPIE and Traditional documentation among selected staff nurses in terms of:
•
Age
•
Gender
•
Time Allotment
•
Year Graduated
•
Mastery on Documentation
•
Years of Clinical
•
Adherence of the staff nurses on documentation
Experience
Figure 1. The Perception of Staff Nurses on SOAPIE and Traditional Documentation Conceptual Framework
The researchers used descriptive type of research. The first box presents the demographic profile of the respondents in terms of age, gender, year graduated and years of clinical experience. The second box discussed the perception on SOAPIE and Traditional documentation among staff nurses in selected hospitals in terms of time allotment, mastery on documentation and adherence of the staff nurses on documentation.
Statement of the Problem
This study aimed to determine the perception on SOAPIE and Traditional documentation among staff nurses in selected hospitals. Specifically, the study sought to answer the following questions: What is the demographic profile of staff nurses in terms of: 1.1 Age 1.2 Gender 1.3 Year Graduated 1.4 Years of Clinical Experience What is the perception of the staff nurses on SOAPIE documentation? What is the perception of the staff nurses on Traditional documentation? Is there a significant relationship between the demographic profile and the perception of staff nurses on SOAPIE documentation?
Is there a significant relationship between the demographic profile and the perception of staff nurses on Traditional documentation? Is there a significant difference between the perception of staff nurses on SOAPIE documentation and the perception of staff nurses on Traditional documentation?
Statement of Hypothesis
Ho. There is no significant relationship between the demographic profile and the perception of staff nurses on SOAPIE documentation. Ho. There is no significant relationship between the demographic profile and the perception of staff nurses on Traditional documentation. Ho. There is no significant difference between the perception of staff nurses on SOAPIE documentation and the perception of staff nurses on Traditional documentation.
Assumption of the Study
This study is premised under the following: 1. That the respondents of the study willingly and honestly answered the questionnaires to the full extent of their knowledge and understanding. 2. That the respondents measured the questionnaires truthfully without any intent of personal gain in mind.
The researchers assumed that since nursing is a dynamic field that the number of years practicing nursing whether in clinical or education area is an accurate measurement of the number of times the nurse is exposed to documentation process.
Scope and Delimitation
The researchers conducted a descriptive study about the perception on SOAPIE and Traditional documentation among staff nurses in selected hospitals last _________ in the selected hospitals namely University of Perpetual Help - Dr. Jose G. Tamayo Medical University and Family Care Hospital. The questionnaires answered by the staff nurses were the primary source of data. The researchers limited the study only to the Perception on SOAPIE and Traditional documentation among staff nurses in selected hospitals.
Significance of the Study
The researchers believed that this study will be beneficial to the following: Nurses will have an awareness regarding SOAPIE and traditional documentation, its importance and possible consequences to the Patients.
Hospital Administration
Clinical Instructors can learn something in this study with regards to documentation, enabling them to provide more information with their students.
Future Researchers can use this study as a reference or guide in making future studies using other variables which were not included in this study.
Definition of Terms The following terms were operationally define Documentation is the process of recording anything that has happened or performed to the patient Perception is the overview of the staff nurses regarding SOAPIE and Traditional documentation SOAPIE is an acronym for Subjective, Objective, Assessment, Planning, Intervention and Evaluation. It is a type of documentation that uses a systematic approach in achieving the patient’s health needs.. Traditional documentation is a type of documentation wherein nurses just record anything that happened or performed to the patient without following a systematic approach. Years of Clinical Experience is the number of years that the staff nurses practiced their profession in the hospital, furthermore, it signifies the amount of experience the respondents have been in clinical area.
Mastery is the possession or display of great skill or technique and/or skill or knowledge that makes one master of a subject Adherence is the act, action, or quality of adhering steady or with faithful attachment
An Undergraduate Thesis Proposal Presented to The Faculty of the College of Nursing University of Perpetual Help, Laguna
In Partial Fulfillment of the Requirements for the Degree of The Bachelor of Science in Nursing
By: De Guzman, Gracielle V. Gutierrez, Alix Roxanne M. Leyva, Arrhenius S. Malabanan, Kristine Allen B. Nullas, Regen Miguel B. Resurreccion, Precious Evangelyn S.
March 2010
Chapter 1 THE PROBLEM AND ITS SETTING Introduction One of the primary purpose of a nurse is to give to the client the better if not, the best nursing care in order for the client to achieve optimum health status. On applying nursing care, every bit of nursing action must be carefully documented to provide continuity of care for the patient. Documentation in general terms is the process of providing evidence or is any communication materials (such as text, video, audio, etc., or combinations thereof) used to explain
some
attributes
of
an
object,
system
or
procedure.
Nursing
documentation clearly describes an assessment of the client’s health status, nursing interventions carried out and the impact of these interventions on client outcomes.
One type of documentation in the nursing field is the use of SOAPIE documentation which is an acronym for Subjective, Objective, Assessment, Planning, Intervention and Evaluation. If you use the SOAPIE format, you’ll document the following information for each problem: Subjective data which consist the information the patient or family members tell you, such as the chief complaint, then the Objective data which are factual, measurable data that are gathered during the assessment, such as observed signs and symptoms, vital signs, and lab test values, Assessment data which includes the conclusions based on the collected subjective and objective data and formulated
as patient problems or nursing diagnoses, It must be systematic and ongoing, And pertinent data are collected using appropriate assessment techniques. Planning which shows your strategy for relieving the patient’s problem including immediate or short term actions and long term measures. It must be individualized to the patient and patient’s condition of needs, Plan is developed with the patient, significant others, and health care providers, when appriopriate. It reflects current nursing practice and provides continuity of care.Intervention which shows the measures you’ve taken to achieve an expected outcome,It is consistent with the established plan of care and implemented in a safe and appropriate manner. Lastly, Evaluation that shows the effectiveness of your interventions.It is systematic, ongoing, and criterion based. In here the nurse evaluates the patient’s progress toward attainment of outcomes. If expected outcomes fall short, alternative interventions should be implemented. Another type of documentation used by the nurses is the traditional or classic type of documentation wherein the nurse just records everything that has been done to the patient without any organized plan or pattern. Perception in humans describes the process whereby sensory stimulation is translated into organized experience. That experience, or percept, is the joint product of the stimulation and of the process itself, thus, every person has their own unique perception in every thing or event that has happened. In this study, the researchers aim to find the perception of staff nurses on SOAPIE and traditional documentation in selected hospitals.
Theoretical Framework
In order to receive information from the environment we are equipped with sense organs example: eyes, ears, and nose. Each sense organ is part of a sensory system which receives sensory inputs and transmits sensory information to the brain. A particular problem for psychologists is to explain the process by which the physical energy received by sense organs forms the basis of perceptual experience. A major theoretical issue on which psychologists are divided is the extent to which perception relies directly on the information present in the stimulus. Some argue that perceptual processes are not direct, but depend on the perceiver's expectations and previous knowledge as well as the information available in the stimulus itself. This controversy is discussed with respect to Gibson (1966) who has proposed a direct theory of perception which is a 'bottom-up' theory, and Gregory (1970) who has proposed a constructivist (indirect) theory of perception which is a 'top-down' theory. Psychologists distinguish between two types of processes in perception: bottom-up processing and top-down processing. Bottom-up processing is also known as data-driven processing, because perception begins with the stimulus itself. Processing is carried out in one direction from the retina to the visual cortex, with each successive stage in the visual pathway carrying out ever more complex analysis of the input. Top-down processing refers to the use of contextual information in pattern recognition. For example, understanding difficult handwriting is easier when reading complete sentences than when reading single and isolated words.
This is because the meanings of the surrounding words provide a context to aid understanding. Iyer, P.W., & Camp, N.H. (1999) states that clear and consistent documentation of the care provided to patients has always played a pivotal role in validating a nurse's legal and ethical responsibilities. Today, the emphasis on increased quality of care at a lower cost places additional challenges on nurses in all settings. Not only must written communication survive the scrutiny of multiple regulatory and accrediting agencies, it must do so without contributing to excessive labor costs Conceptual Paradigm Independent Demographic Profile in terms of:
Dependent Perception on SOAPIE and Traditional documentation among selected staff nurses in terms of:
•
Age
•
Gender
•
Time Allotment
•
Year Graduated
•
Mastery on Documentation
•
Years of Clinical
•
Adherence of the staff nurses on documentation
Experience
Figure 1. The Perception of Staff Nurses on SOAPIE and Traditional Documentation Conceptual Framework
The researchers used descriptive type of research. The first box presents the demographic profile of the respondents in terms of age, gender, year graduated and years of clinical experience. The second box discussed the perception on SOAPIE and Traditional documentation among staff nurses in selected hospitals in terms of time allotment, mastery on documentation and adherence of the staff nurses on documentation.
Statement of the Problem
This study aimed to determine the perception on SOAPIE and Traditional documentation among staff nurses in selected hospitals. Specifically, the study sought to answer the following questions: What is the demographic profile of staff nurses in terms of: 1.1 Age 1.2 Gender 1.3 Year Graduated 1.4 Years of Clinical Experience What is the perception of the staff nurses on SOAPIE documentation? What is the perception of the staff nurses on Traditional documentation? Is there a significant relationship between the demographic profile and the perception of staff nurses on SOAPIE documentation?
Is there a significant relationship between the demographic profile and the perception of staff nurses on Traditional documentation? Is there a significant difference between the perception of staff nurses on SOAPIE documentation and the perception of staff nurses on Traditional documentation?
Statement of Hypothesis
Ho. There is no significant relationship between the demographic profile and the perception of staff nurses on SOAPIE documentation. Ho. There is no significant relationship between the demographic profile and the perception of staff nurses on Traditional documentation. Ho. There is no significant difference between the perception of staff nurses on SOAPIE documentation and the perception of staff nurses on Traditional documentation.
Assumption of the Study
This study is premised under the following: 1. That the respondents of the study willingly and honestly answered the questionnaires to the full extent of their knowledge and understanding. 2. That the respondents measured the questionnaires truthfully without any intent of personal gain in mind.
The researchers assumed that since nursing is a dynamic field that the number of years practicing nursing whether in clinical or education area is an accurate measurement of the number of times the nurse is exposed to documentation process.
Scope and Delimitation
The researchers conducted a descriptive study about the perception on SOAPIE and Traditional documentation among staff nurses in selected hospitals last _________ in the selected hospitals namely University of Perpetual Help - Dr. Jose G. Tamayo Medical University and Family Care Hospital. The questionnaires answered by the staff nurses were the primary source of data. The researchers limited the study only to the Perception on SOAPIE and Traditional documentation among staff nurses in selected hospitals.
Significance of the Study
The researchers believed that this study will be beneficial to the following: Nurses will have an awareness regarding SOAPIE and traditional documentation, its importance and possible consequences to the Patients.
Hospital Administration
Clinical Instructors can learn something in this study with regards to documentation, enabling them to provide more information with their students.
Future Researchers can use this study as a reference or guide in making future studies using other variables which were not included in this study.
Definition of Terms The following terms were operationally define Documentation is the process of recording anything that has happened or performed to the patient Perception is the overview of the staff nurses regarding SOAPIE and Traditional documentation SOAPIE is an acronym for Subjective, Objective, Assessment, Planning, Intervention and Evaluation. It is a type of documentation that uses a systematic approach in achieving the patient’s health needs.. Traditional documentation is a type of documentation wherein nurses just record anything that happened or performed to the patient without following a systematic approach. Years of Clinical Experience is the number of years that the staff nurses practiced their profession in the hospital, furthermore, it signifies the amount of experience the respondents have been in clinical area.
Mastery is the possession or display of great skill or technique and/or skill or knowledge that makes one master of a subject Adherence is the act, action, or quality of adhering steady or with faithful attachment
