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?

Choice A: This is the correct answer. A portal is a secure online platform that enables clients to access their health information, communicate with their providers, request appointments, refill prescriptions, and more. This enhances client satisfaction, engagement, and empowerment.
Choice B: This is incorrect. Same day access to client health record is not an advantage of electronic documentation, but a requirement for any documentation system. Clients have the right to access their health information within a reasonable time frame, regardless of whether it is paper-based or electronic.
Choice C: This is incorrect. The increase of duplicate tests performed on client is not an advantage of electronic documentation, but a disadvantage. Duplicate tests can result from poor communication, lack of interoperability, or human error. Electronic documentation can help reduce duplicate tests by facilitating data sharing, standardizing formats, and alerting providers of previous tests.
Choice D: This is incorrect. Decrease in coordination of client care is not an advantage of electronic documentation, but a disadvantage. Coordination of client care is essential for ensuring quality, safety, and continuity of care. Electronic documentation can improve coordination of client care by allowing multiple providers to access and update the same information, enabling real-time collaboration, and providing decision support tools.

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.