Source vs Problem-Oriented Documentation Workflow
Key Points
- Source-oriented documentation organizes by discipline; problem-oriented documentation organizes by patient problem.
- Source-oriented tools commonly include admission sheets, flow sheets, and narrative notes.
- Problem-oriented formats include SOAP, SOAPIER, focused charting, and charting-by-exception variants.
- Model choice should support clarity, continuity, and rapid clinical decision-making.
Equipment
- EHR charting templates for source-oriented and problem-oriented entries
- Approved abbreviation list and institutional documentation policy
- Current patient problem list and care-plan goals
Procedure Steps
- Identify whether the charting purpose is discipline-specific reporting or problem-specific tracking.
- Use source-oriented documentation when tracing entries by discipline and chronology is the primary need.
- Use problem-oriented documentation when tracking patient issues, interventions, and outcomes across disciplines.
- For problem-oriented notes, select SOAP/SOAPIER structure and populate each section consistently.
- Ensure subjective and objective data are clearly separated before assessment conclusions.
- Document plan/interventions and immediate patient response with time-stamped entries.
- Add evaluation (and revision if using SOAPIER) when response data suggest care-plan adjustment.
- Review the note for completeness, readability, and objective language before signing.
Common Errors
- Mixing model logic in one note → confusing care continuity.
- Omitting response/evaluation in problem-oriented notes → weak outcome tracking.
- Overusing narrative detail without key data points → slower clinical interpretation.
- Redundant multi-discipline duplication in source-oriented charts → fragmented records.
Related
- ana-nursing-documentation-principles - Quality and safety standards that apply to all charting models.
- primary-secondary-objective-subjective-data - Data structuring foundation for SOAP/SOAPIER notes.
- evaluation-of-outcomes-in-fluid-electrolyte-and-acid-base-care - Example of outcome-linked documentation cycles.