A nurse is documenting in a client's health record using the subjective, objective, assessment, and plan (SOAP) charting model. Which of the following information should be included in the subjective component?

The correct answer is: c. Less time for direct client care

Choice A: Decreased amount of paperwork

Reason: One of the advantages of electronic charting is that it significantly reduces the amount of paperwork. Traditional paper records require extensive manual documentation, which can be time-consuming and prone to errors. Electronic systems streamline this process, making it easier to input and retrieve patient information. Therefore, decreased paperwork is a benefit, not a challenge.

Choice B: Increased number of medication errors

Reason: Electronic charting systems are designed to reduce medication errors by providing features such as electronic prescribing, automated alerts for potential drug interactions, and barcode scanning for medication administration. These systems help ensure that the right medication is given to the right patient at the right time, thereby decreasing the likelihood of errors. Hence, increased medication errors are not typically associated with electronic charting.

Choice C: Less time for direct client care

Reason: One of the significant challenges of electronic charting is that it can be time-consuming, requiring nurses to spend a considerable amount of time on documentation. This can reduce the time available for direct patient care. Nurses often report that the demands of electronic documentation can detract from their ability to engage with patients, perform assessments, and provide hands-on care.

Choice D: Provides evidence of care provided

Reason: Providing evidence of care is a benefit of electronic charting, not a challenge. Electronic health records (EHRs) create a detailed and accurate record of the care provided, which can be easily accessed and reviewed. This documentation is crucial for legal, regulatory, and quality improvement purposes. Therefore, this option does not represent a challenge.

Choice A reason: Critical thinking is a component of clinical decision-making that the nurse should use to make an evidence based decision. Critical thinking is the process of applying logic, reasoning, analysis, and evaluation to the information and evidence that is available. Critical thinking helps the nurse to identify and question assumptions, biases, and gaps in the data, and to draw valid and reliable conclusions based on the best available evidence.
Choice B reason: Clinical judgement is not a component of clinical decision-making, but an outcome of clinical decision-making. Clinical judgement is the result of applying critical thinking and clinical reasoning to the data and evidence that is gathered and interpreted. Clinical judgement is the expression of the nurse's decision or opinion about the client's situation, needs, and interventions.
Choice C reason: Concept mapping is not a component of clinical decision-making, but a tool or a strategy that can facilitate clinical decision-making. Concept mapping is a visual representation of the relationships among concepts, data, and evidence that are relevant to the client's situation. Concept mapping can help the nurse to organize, synthesize, and analyze the information, and to identify patterns, themes, and gaps in the data.
Choice D reason: Clinical reasoning is not a component of clinical decision-making, but a process that is involved in clinical decision-making. Clinical reasoning is the cognitive process that the nurse uses to collect, process, interpret, and integrate the data and evidence that is available. Clinical reasoning helps the nurse to make sense of the client's situation, needs, and responses, and to select the appropriate interventions and actions.