1. Gedney-Lose, Amalia DNP, ARNP, FNP-C

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The shift from flowsheet documentation, often used by bedside nurses, to documentation using the subjective, objective, assessment, and plan (SOAP) format can be challenging for nurse practitioner students. Documentation is a skillset that requires repetition to ensure competency, appropriate detail, and timely completion. Nurse practitioner students should collect a detailed history of present illness (HPI), review of systems (ROS), physical examination (PE), diagnosis, and plan containing pertinent patient information. Often, patients will present for a single chief complaint that expands into multiple concerns during the visit. Skilled clinicians will be able to adapt the visit to meet the patient's needs, but this can be a difficult concept for novice students. Nurse practitioner students in their first semester of clinical practicum were having a difficult time identifying and documenting necessary information associated with each patient complaint. Therefore, a SOAP note using a color-coding system was provided as a visual aid. The SOAP contained 3 patient complaints and 3 colors: headache (green), seasonal allergies (orange), and diabetes mellitus type 2 (blue) (Supplemental Digital Content,, Example). Every documented item was color coded showing the relationship to the HPI and overall patient picture. It helped students who were doing a 12-point ROS on a simple problem (eg, sore throat) focus their note, while showing students who had minimal documentation that they needed to identify all pertinent information. Students noted that this visual aid was helpful in tying the HPI, ROS, PE, assessment, and plan together, leading to an overall improvement in SOAP note documentation.