This article provides a sample solution to Discussion – Clinical Experience.
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Unit 9 Discussion – Clinical Experience
In clinical practice, effective care delivery must incorporate healthcare records if essential communication between the healthcare providers and fulfillment of the duty of care is to be achieved. This constitutes the interchange of high-quality information guided by evidence-based healthcare service for consumers.
In my clinical experience, I have witnessed how the use of SOAP Notes by psychiatric and mental health care nurses as a structure for patient-provider documentation facilitates appropriate clinical decision making while also serving as evidence of critical thinking. The SOAP notes highly structured format documents the progress of patient care since the notes ensure improved quality and continuity of care of the individual (Lenert, 2016).
In the healthcare organization where I work, I have witnessed firsthand how the SOAP notes, whether comprehensive or focused, enhance communication among the multidisciplinary care team, helping to identify, prioritize, and track a specific client’s needs. Once identified, these needs are then addressed in a timely and systematic way. As noted in the author’s mental health facility, equipping nurses with skills on preparing SOAP Notes Framework calls for an in-depth understanding of the topic area (Wang et al., 2015). Furthermore, the advent of electronic health records demands that all psychiatric care providers consider how written records affect the patient’s openness during psychotherapy sessions and the amount of information provided to document within the psychiatric records.
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Most importantly, I have observed that this healthcare organization has set standards that clarify that psychotherapy notes must not be stored together with the other general medical records (Corley, 2012). There is also a provision stating that psychotherapy notes may only be released following the client’s written authorization in context.
References
Corley, S. O. (2012). Protection for psychotherapy notes under the HIPAA privacy rule: As private as a hospital gown. Health Matrix, 22, 489.
Lenert, L.A.(2016). Toward medical documentation that enhances situational awareness learning. In AMIA Annual Symposium Proceedings (Vol.2016, p. 763). American Medical Informatics Association. 2016
Wang, X.Q., Wang, R., & Chen, P.J.(2015) Application of SOAP assessment note to rehabitlitation therapy teaching. Chineses Journal of Tissue Enginnering Research, 19(5), 805.
