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University of the East

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER INC.

#64 Aurora Boulevard, Barangay Doña Imelda, Quezon City

COLLEGE OF NURSING

In Partial Fulfillment of Requirements in

Nursing Research

THE COMPLIANCE OF STUDENT NURSES TO STANDARD

DOCUMENTATION OF SOAPIE IN UERM HOSPITAL:

A DESCRIPTIVE STUDY

SUBMITTED BY:



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Venturina, Paulo Gabriel

BSN4-G26

SUBMITTED TO:

LEVEL IV FACULTY

AUGUST 13, 2010

CHAPTER 1

Introduction

During clinical duties, one of the primary responsibilities of a student nurse is to

accomplish a SOAPIE which is considered as the legal document of the patient. This

contains all the interventions and focused nursing care which is done to the patient.

During these clinical duties, the investigators noticed reports of non-compliance to



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A study was published in the Archives of Internal Medicine based on data

collected since 1999. In the Philippines, more than 80 potentially harmful errors on

documentation a day were found on average in hospitals. The most common mistake in

writing documentation is the usage of abbreviations and undocumented orders that are

carried out by the nurses. Errors occurred in one of five patients in a typical 300-capacity

patient. This translates to an average of 4 errors per patient daily. Although not all of

these errors are dangerous, 7% of the errors were considered potentially harmful. Errors

can lead to manslaughter charges. It is the nurse’s role to help improve the quality of care

and proper documentation by providing standards, errors can be minimized, if not

completely eradicated at the clinical side. Its occurrence reflects on the quality of health

care.

Since documentation is considered as a legal document of the patient and a means

of communication to health care professionals, the investigators would like to be



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The purpose of this study is to determine the relationship between compliance on

standard documentation of SOAPIE of the selected student nurses by year and ward

placement in UERM hospital.

Statement of the problem

This study generally aimed to analyze the relationship of Selected Student nurses

Compliance to Standard Documentation of SOAPIE in UERM hospital and their year and

ward placement.

Specifically it sought to answer the following questions:

1. What is the compliance on standard documentation of SOAPIE of selected



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The participants included in the study are the charts accomplished by selected

student nurses of UERMMMCI entering wards for their clinical duty. The number of

charts included in the study is 60% of the total average census of patients admitted in the

wards utilizing standard documentation of SOAPIE at UERM hospital.

The investigators looked through the Nurse’s Notes accomplished by the Student

nurses and tallied the most and least committed errors in regards to compliance on the

standard documentation of SOAPIE. There were criteria which served as a basis for

compliance to standard documentation of SOAPIE.

All the charity and private wards were included in the study but only utilized

selected charts for auditing chosen through simple random sampling. The wards included

in the study are the 3 North 2, 4 North, 4 South, 4 East, ICU,CCU, Ob-gyne ward,

Pediatric ward, Surgery ward, Medical ward, EENT.



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The constraints the investigators had encountered includes inability to acquire

data from 3 NORTH 1, Neurology ward and Psychiatric ward. 3 North 1 is under

renovation during the time of data collection so no charts are subjected to study.

Neurology and Psychiatric ward were not included in the study because there is a

different format for documentation. Other than that, the investigators are not familiar with

the format.

The investigators could not include look into the relationship between compliance

to standard documentation of SOAPIE and ward placement because there are only limited

student nurses on duty on the areas which are considered acute. The acute areas would

includes ICU, Obgyne, EENT, Pediatric ward and CCU. Other than that, the variations in

the number of students assigned per ward are not equally distributed amongst the acute

and the chronic area. The effect of this would alter the results of the study if the

investigators would still include ward placement in the study.



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Definition of Terms

This study sought to determine compliance among student nurses. The terms used in the

styudy are the following:

1. Compliant

- the student nurse was able to follow 12 or more out of 15 criteria on

standard criteria on documentation of SOAPIE in UERM hospital.

2. Non-compliance

- the student nurse was able to follow less than 12 out of 15 criteria on

standard criteria on documentation of SOAPIE in UERM hospital.

3. Chart audit

- is an examination of medical records through open charting to determine



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CHAPTER 2

Compliance to documentation and the quality of care to patients.



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student nurses’ and registered nurses’ knowledge in the importance of documentation and

its implication, there are still a huge number of cases wherein they lack compliance in

standard documentation.

Day (2008) cited that the reason why nurses don’t comply is that they view

documentation as time consuming. Rather than documenting in the nurses’ notes, they

should be spending more time with their patients to tend their needs. And to the nurses

who do give time to document, it poses a number of errors and incongruence. According

to the American Nurses’ Association, the most common form of error committed in

documentation is the use of abbreviations. Abbreviations may pose meanings that are

different from what they intend to inform. Even phrases pose the same thing. Nurses are

supposed to be communicators, especially when documenting patient information. If

what they write does not communicate, then they have failed in our professional and legal

responsibilities. Furthermore, they have failed our patient and our employer, thereby



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caregivers. The positive effect of compliance to patients is that the provision of care will

be best identified because all the care rendered and all possible care to be rendered will

be fully understood by the registered and student nurses that would be on duty in the

succeeding shifts. To the hospital and to the caregivers, they will hold no liability in case

an accident occurs in the patient as long as the nurses did not fall short in providing care

and documenting it. However, the negative effect in compliance to documentation is that,

because of too much time being consumed in documentation, the caregivers tend to fall

short in proving care. Rather than documenting in details, the nurses should have been in

the patients’ bedside attending their needs.

Non-compliance to standard documentation may also present a positive effect,

because direct identification and description of the care provided during endorsement is

better understood than reading it in the nurses’ notes. Nurses are more comfortable

endorsing it vocally rather that reading it in charts. According to them, this also consumes

too much time.



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“It must be objective, legible, free of grammatical and spelling errors, free

of errors or erasures, completed in blue or black ink, accurate, and use of

medically approved abbreviations. Late entries and any corrections entered

should be per policy and procedure. Allergies should be highlighted and

flow sheets filled out completely. No charting should be done in advance.”

Gaps in standard documentation protocol

In relation to the previous case study stated, other investigators view that the

problem is not merely in the registered or student nurses rather the current standard form

of documentation. A review carried out by Karkkainen, Bondas, and Eriksson (2005)

tends to determine how well individualized patient care was represented in nursing

documentation. Karkkainen and coworkers identified three themes in the literature

reflecting the tensions in the record: demands of the organization, nurses’ attitudes and

duties, and the patient’s involvement in care. In conclusion, Karkkainen, Bondas, and



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Behaviors of nurses in documenting interventions.

Some investigators even view that health professionals’ attitudes towards

documentation greatly affects their compliance. According to a case study conducted by

Oldfield (2006), initiative could impact behavioral changes in the hospital setting, and

that such changes could impact documentation. Improving the documentation could

potentially improve hospital revenue. Through direct monitoring of their documentation

and giving penalties to those who fail to comply, compels them to follow the standard

documentation. Initiation may also be achieved through positive reinforcement and

proving an easier process on how to document.

Ngin (1993) further found out that nurses relied less on the formal forms of

documentation in the medical record and the care plan than on informal sources; her

subjects preferred getting information directly from other nurses who had first-hand,



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reasons that nurses face malpractice suits. In terms of overall completeness, Stokke and

Kalfoss (1999) found many gaps in nursing documentation in Norway. Care plans, goals,

diagnoses, planned interventions, and projected outcomes were absent between 18

percent and 45 percent of the time. Taylor (2002) found that many of the care plans

reviewed did not convey the specific information necessary to carry out the required

procedure. One Third of the nurses in their study mentioned accessing written

documentation but did not express any preference for care plans.

The evidence reviewed in studies cited above suggests that formal recordkeeping

practices are failing to fulfill their primary purpose, of supporting information flow that

ensures the continuity, quality and safety of care. Moreover, disproportionate attention to

secondary purposes (e.g., accreditation and legal standards) has produced a medical

record that is document centered rather than patient focused. Cumbersome and variable

formats, useless content, poor accessibility, and shadow records are all evidence of the

extraordinary failure of the medical record. Given the exorbitant cost of the record and



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Figure 1. conceptual framework of compliance to standard documentation of SOAPIE to year

placement

The domain of learning such as the cognitive (knowledge), affective (attitude), and

psychomotor (behavior) together with the year placement will affect a student’s inner

ability to comply to the set standard for documenting SOAPIE.

Year placement (3rd/ 4th

year)

Compliance to standard

Documentation of SOAPIE

-Knowledge of student nurses

-Behavior of student nurses

Ward placement (Pay/

service)



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There is a significant relationship between the compliance in standard

documentation of SOAPIE to year placement. There is no significant relationship

between ward placement and compliance of student nurses to SOAPIE as a standard

documentation.

CHAPTER 3

METHODOLOGY



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between compliance to standard documentation of SOAPIE to year placement in UERM

hospital. Its main objective is the accurate portrayal of the frequency of SOAPIE non-

compliance of student nurses.

The primary data used in the study were nominal in nature and the figures showed

the frequency of non-compliance in a specific category created by the investigators in

accordance to the UERM hospital standards. Thus, quantitative type of study was used.

The researchers used a quantitative approach because they will be extracting a

numerical data out of a formal measurement which will be analyzed by their statistical

treatment. This is done to measure the error frequency of student nurses in accordance to

compliance to standard documentation while on their clinical exposures at UERM

hospital.

On the other hand, the descriptive research is the research that has its main objective of



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The respondents in the study were the charts accomplished by the student nurses

in the wards during clinical duty at UERM hospital. The investigators got the 60 % of the

average census of patients admitted at UERM hospital in wards utilizing SOAPIE as a

standard documentation in the Nurses Notes. The average census of patients admitted in

UERM hospital is 85. The investigators performed open charting on the selected 60% of

the total charts in the hospital.

Sampling Technique

Out of the total chart population in the entire hospital, the investigators utilized

the charts in the wards where in SOAPIE is used as a standard documentation in the

Nurses Notes.



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In the study, the investigators acquired the format for standard documentation of

SOAPIE in UERM hospital. The investigators communicated with the Nursing service of

the said hospital to be able to formulate accurate criteria for standard documentation of

SOAPIE. After we coordinated with the chief nurse, Mrs. Aida Agbayani, we provided

revisions for an accurate guideline in standard documentation of SOAPIE.

After the selection of population of the target population and formulation of

criteria, the investigators secured informed consents to the head of the nursing

administration in UERM hospital as well as to the research heads of the research

department. The informed consent indicated that any information obtained shall at all

times be kept private. This consent also included the focus of the study, the population

included and lastly, the data processing collection. After the letter has been approved by

the respected personnel for the study, the investigators proceeded to data collection.



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In determining the compliance of the student nurses regarding standard

documentation of SOAPIE, the investigators conducted chart auditing through open

charting. The investigators evaluated the audited patient’s profile chart to directly

measure compliance to standard documentation. The SOAPIE in the Nurses’ Notes will

be the subject of the study and in congruence with its content; the investigators looked

into the Doctor’s order and review patient’s condition based on the contents of the charts.

In interpreting the data for measuring the compliance of the student nurses to

standard documentation of SOAPIE, the investigators used a systematic grading system

in evaluating the checklist as part of their auditing of patient’s profile charts. The

investigators checked whether the student nurses complied with the doctor’s order

through looking at their documentations. It is believed that any nursing intervention done

by students in correlation to the doctor’s order should always be written because it will

serve as a legal basis for nursing practice.



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Statistical Treatment

This study being a descriptive correlational research, made use of frequency

tables and percentages for its statistical treatment. The investigators used a quantitative

approach because they extracted a numerical data out of a formal measurement which

was analyzed by the statistical treatment. This was done to measure the non-compliance

frequency of student nurses in accordance to compliance to standard documentation

while on their clinical exposures at UERM hospital.

The Chi test was utilized by the investigators to show the significance of the

relationship between ward and year placement and compliance of student nurses to

SOAPIE on standard documentation. Only those who got 80 percent of the total score of

the standard criteria of SOAPIE documentation was considered compliant and therefore

was treated by chi test to determine the relationship between two variables.



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Timeline

The researchers systematically managed the time for the study. From the initial steps in

formulating up to data analyzation and recommendation, the researchers alloted time for

each phases to be able to come up with an organize and reliable study regarding the

compliance of student nurses to standard documentation of SOAPIE in UERM hospital.

The researchers asked permission to the institution, nurse on duty, clinical instructors andrespondents to conduct a research study.

CHAPTER 4

This chapter presents the tables containing the data in the study regarding compliance of

student nurses to standard documentation of SOAPIE. It also shows the analysis and



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See appendix A for specific distribution of charts per year and ward placement.

This table shows the distribution of clients made by third year and fourth year

student nurses in both pay and service clinical area. Most charts that are audited in the

service ward were done by the third year which accounts to 78 percent of the student

nurses, while in pay ward most are done by fourth year students.

In pay ward, CCU has the least number of charts audited because there were less

student nurses assigned in the area. Among all the pay wards, 3north2 has the most

number of audited charts. In service ward, medical and surgical wards top the number of

audited charts and most of it was done by the third year student nurses. The least number

of audited charts were in ICU, where student nurses are limited in the area.

Table

2 shows third

Table 2

Frequency distribution of compliance of standard

documentation by year placement in UERM hospital N=51

Year Level



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students. On the other hand, there is compliance to the 83% of the total 18 fourth year

students.

This reveals a chi square of 11.7, degree of freedom (df) is 1 and chi square’s

critical value (X2cv) is 3.841. Since the chi square value is greater than the critical value,

then, the alternative hypothesis that there is a significant relationship between the

compliance in standard documentation of SOAPIE to year placement is retained. The

confidence level of the study is 95 % since the Alpha is 0.05 . (See Appendix E )

Table 3

Frequency distribution of compliance of standard documentationby ward placement in UERM hospital N=51

Ward.



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This reveals a chi square of 3.59, degree of freedom (df) is 1 and chi

square’s critical value (X2cv) is 3.841. Since the critical value is greater than the chi

square, then, the null hypothesis that there is no significant relationship between ward

placement and compliance of student nurses to SOAPIE as a standard documentation is

retained. The confidence level of the study is 95 % since the Alpha is 0.05. (See

Appendix F )



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To acquire the data needed, the investigators used the random sampling as the

method. Through open charting, 60% of the charts of the total population of the patients

admitted in the hospital were evaluated if there is compliance or noncompliance to the

standard documentation. The SOAPIE documentations included are the ones made by the

Third year and Fourth year student nurses only.

Based from the data gathered by the investigators, table 2 showed that the

greater the exposure of the student nurses to SOAPIE documentation, the higher the

compliance. This reveals a chi square of 11.7, degree of freedom (df) is 1 and chi

square’s critical value (X2cv) is 3.841. The confidence level of the study is 95 % since the

Alpha is 0.05. Since the chi square value is greater than the critical value, then, the

alternative hypothesis that there is significant relationship between compliance of student

nurses to standard documentation of SOAPIE to year placement, is retained.

This is justified by Todd (2006)’s by proving that the students know more as they



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increasingly more factual statements to represent their knowledge throughout the three

stages.

Table 3 showed that there is no significance between the compliance of student

nurses to standard documentation of SOAPIE to ward placement. The ward placement

does not depend on their performance on documentation. The chi square of 3.59, degree

of freedom (df) is 1 and chi square’s critical value (X2cv) is 3.841. The confidence level of

the study is 95 % since the Alpha is 0.05. Since the critical value is greater than the chi

square, then, the null hypothesis that there is no significant relationship between

compliance of student nurses to standard documentation of SOAPIE to ward placement,

is retained.

This is justified by Currell,(1988) who focused on nursing record systems as

variations in the systems effect nursing practice and patient outcomes reveals the tensions

surrounding nursing documentation. These include, the amount of time spent documenting;



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The investigators would like to recommend the following actions to the next

interested investigators for the improvement of this study. The study should not be

limited to the nurse’s notes only, rather the whole chart where nurses’ document, this

includes the temperature ,pulse and respiration (TPR) sheet, input /output monitoring

sheet, medication sheet, graphic chart, intravenous monitoring sheet and patient’s profile.

The study should also not be limited to the Third year and Fourth year students

only, rather to all levels of the nursing department that are allowed to document in the

hospital wards. Registered nurses’ documentation should also be included in the

population. The study’s population should also not be limited to 60% only, rather be

increased to 80-85% or include all the total number of patients in the hospital. In this

manner, the study will be further elaborated for better evaluation of the compliance of

standard documentation in the hospital wards.



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Appendix



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APPENDIX A

Table 4 .DISTRIBUTION OF CHARTS BY YEAR LEVEL AND WARD

HOSPITAL CENSUS



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WARD CHART

NUMBER

SAMPLE

POPULATION

SELECTED

THROUGH

SIMPLERANDOM

SAMPLING

CHARTS

ACCOMPLISHED BY:

3RD YEAR 4TH YEAR

PAY

3 NORTH 2 320321

322

323324325

326

327329

330

331

332

4 NORTH 425

426

427

428430

435

436437



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Appendix B

Consent form

University of the East

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER INC.College of Nursing

Aurora Blvd, Quezon City



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premises of the hospital. The research will randomly select five (5) charts per ward with

odd numbers. This is to avoid possible biases.

The investigators would like to ensure that the data implementation will be held

confidential. Other than that, no RLE duties or other health care professionals on duty

will be affected.

We are hoping for your kind consideration

Respectfully yours,

_Perly Marie M. Lazaga_________ Leader of Group G-26

Noted by: _______________________

WILHELMINIA ATOS, R.N., PHD

Professor, Nursing Research

APPENDIX C

Sample criteria of standard SOAPIE documentation



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CRITERIA Done Not

Done

The SOAPIE should be written in the nurse’s notes.

The appropriate date and time when the SOAPIE was

written should be located on the upper left corner of the SOAPIE.

The SOAPIE should be written in the corresponding patient’s chart

The SOAPIE should be written in sequential manner

The SOAPIE should be written with completeness (allelements of SOAPIE are present)

The SOAPIE should be written without super impositions

The contents of SOAPIE should not contain anyabbreviation

The contents of SOAPIE should have the correct usage

of grammar

The contents of SOAPIE should be written with correctspelling

The objective should be written with complete

assessment (eg. IV fluids, heplock, general

assessments)



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Appendix D

Table 5. Critical Values for the Chi-Squared Distribution

A

df 0.995 0.99 0.975 0.95 0.9 0.1 0.05 0.025 0.01 0.005

1 0.000 0.000 0.001 0.004 0.016 2.706 3.841 5.024 6.635 7.879

2 0.010 0.020 0.051 0.103 0.211 4.605 5.991 7.378 9.210 10.597

3 0 072 0 115 0 216 0 352 0 584 6 251 7 815 9 348 11 345 12 838



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X2= 11.7

dF Α p Cv

1 0.05 0.001 3.841

Ha = There is a significance between the compliance of standard documentation of

SOAPIE with the year placement of the student nurses in UERM hospital.

This reveals a chi square of 11.7, degree of freedom (df) is 1 and chi square’s critical

value (X2cv) is 3.841. Since the chi square value is greater than the critical value, then, the

alternative hypothesis is retained. The confidence level of the study is 95 % since the

Alpha is 0.05 .

Appendix F

Table 7. Frequency distribution of compliance of standard documentation by ward placement in UERM hospital

f f (f f 2



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Hn = There is no significance between the compliance of student nurses to standard

documentation of SOAPIE to ward placement. The ward placement does not

depend on their performance on documentation.

The chi square of 3.59, degree of freedom (df) is 1 and chi square’s critical value (X 2cv) is

3.841. The confidence level of the study is 95 % since the Alpha is 0.05. Since the critical

value is greater than the chi square, then, the null hypothesis that there is no significant

relationship between compliance of student nurses to standard documentation of SOAPIE

to ward placement, is retained.

Appendix G

Conceptual Framework




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The domain of learning such as the cognitive (knowledge), affective (attitude), and

psychomotor (behavior) together with the year placement will affect a student’s inner

ability to comply to the set standard for documenting SOAPIE.


Documentation of SOAPIE



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Appendix H

Timeline

The investigators systematically managed the time for the study. From the initial

steps in formulating up to data analyzation and recommendation, the investigators alloted

time for each phases to be able to come up with an organize and reliable study regarding

the compliance of student nurses to standard documentation of SOAPIE in UERM

hospital. The investigators asked permission to the institution, nurse on duty, clinical

instructors and respondents to conduct a research study.



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TIMELINE

JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST

ACTIVITY 1 2 3 4 1 2 3 4 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 1 2 3 4

Topic selection

Feasibility of the

study, respondents,chapter 1 draft

Defense of the chosen

topic

Conceptual/theoretical

framework

Finalized draft of

chapter 1 and 2

edit chapter 2

(literature review)

Finalized chapter 1

and 2

Formulation of

Statistical treatment

Gathering of criteria

of standard

documentation

Approval of letter of

research heads

Letter revisionApproval of letter of

the hospital

Pretesting

Data collection

Analyzation and

interpretation of data

Study conclusion

Formulation of

RecommendationCreation of Final

paper

Defense of final study



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