Level of Knowledge, application of quality requirements in nursing notes and legal implications

Abstract

The SOAPIE nursing note (Subjective Data, Objective Data, Analysis, Planning, Intervention and Evaluation) is a written record of observations made on the patient, considering their physical, mental, and emotional state, as well as their progress, care and procedures. Objective: To describe the degree of knowledge, application of quality requirements in the preparation of nursing notes and the legal implication of the Professional Nursing staff of the maternal and surgical blocks of the Leonardo Martínez Valenzuela Hospital in 2023. Materials and methods: This is a mixed-approach, descriptive, cross-sectional study; a sample of 50 Nursing Graduates was used; the techniques used were the questionnaire and observational guide for the quantitative component; and an in-depth interview guide for the qualitative component, applied to 4 lawyers from the legal department. Results: Regarding basic knowledge of the components of the nursing note, it was found that 26 (52%) had moderate knowledge and 18 (36%) had low knowledge. Regarding basic knowledge of the structure of the note, 29 (58%) had a low level of knowledge and 14 (28%) a moderate level of knowledge. In the application of quality requirements, 31 (62%) of the participants partially met the requirements and 10 (20%) fully met them. The lawyers interviewed agreed that nursing notes should be legible, clear and have better spelling, and that the notes of the personnel in question do not have these qualities. Conclusion: Most professionals are categorized between moderate and low according to their level of knowledge, so their applicability in the nursing note is of low quality, putting interdisciplinary communication and the continui- ty of nursing care at risk.