CNPP students are expected to chart using a subjective, objective, assessment, and plan (SOAP) note.
- The student will complete a written SOAP note for each patient encounter. It must be written in a clear succinct method (Podder, Lew & Ghassemzadeh, 2020).
- The student will chart the SOAP notes either electronically or in paper charts or files. Preceptors are required to review each note to ensure accuracy and will co-sign the note, a legal requirement of care.
- Preceptors will provide feedback and guidance to help students improve their charting. It is recommended that students who are in the learning phase do not use electronic macro adjustments in charting as this may impede their learning. Writing a succinct note that communicates effectively is a critical skill that NP students must develop.
Electronic Health Records (EHRs)
The introduction of EHRs (electronic health records) presents obstacles for students if they lack a password or are not fully trained in the use of one institution’s EHR system. Ideally, students should be offered EHR training that is specific to the clinical agency prior to commencing any clinical hours.
It is not advisable for a student to chart under the preceptor’s username and password. In these cases, students are encouraged to hand-write notes which then should be reviewed by preceptors.
The preceptor cannot bill for the services of a student. Preceptors are required to document the services they provide as well as review and edit all student documentation. Students’ notes are legal and will contribute to the medical record.
Students are expected to write prescriptions, order diagnostics, write referrals, and consult letters for the patient. The preceptor must co-sign all clinical documents.