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7. Written communication

7.1. Written documentation standards

medicine, people and healthcare concept - close up of female doctor or nurse writing medical report to clipboard at hospital

Written documentation in health care records must comply with the following:

  • be objective, relevant, clear and accurate
  • be legible and in English
  • be accurate statements of clinical interactions
  • use only approved abbreviations and symbols
  • written in dark ink, not red or other coloured ink
  • use a 24 hour clock to record time of entry and for date of entry use ddmmyy or ddmmyyyy
  • signed by the author, and include printed name and designation, or electronic signature for electronic medical record (entries by students involved in the care and treatment of a client must be co-signed by the student’s supervising clinician).

SOAP is a format for written documentation in a client’s health care record that is used by AHAs.

Select each letter to find out about SOAP.

Subjective

In this section, the AHA documents what the person reports as to how they are feeling (eg pain, fatigue, nausea) prior to the therapy session commencing. The three point ID check and consent for therapy gained is also documented in this section.


Objective

In this section, the AHA documents what they have observed during the delegated therapy session. Observations of functional tasks and the level of assistance required to complete these tasks are documented and documentation confirms the AHP assessment of these tasks. The AHA is only document what they observe during the session. 

Observations reported in this section include: 

  • vital signs including blood pressure, heart rate, oxygen saturations 
  • current function and level of assistance 
    • transfers 
    • mobility 
    • stairs 
    • ADLs 
    • equipment used.


Action

In this section, the AHA documents what tasks they have completed during the therapy session. More specific details include what therapy tasks were completed, how the person coped with the therapy tasks, and if any task did not go to plan. If there was a task that did not go to plan, the AHA is required to document what happened, what they did about it, and what the outcome was.


Plan

In this section, the AHA documents the plan following the therapy session and usually includes a plan to provide feedback to the delegating AHP and when the person will complete their next session of therapy.

Reference: Health Care Records - Documentation and Management, NSW Health, Accessed 26/05/2024.

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