Charting in the clinical setting: SOAP, COWs, AI, and beyond!

We will explore the transition of charting in the clinical setting focusing on pre technology (Narrative + SOAP), emerging technology (COWs) and future technology (AI) during this conversation. While the integrity of the chart (medical record) continues to be paramount in terms of legal terms, there has been a noticeable adaptive change in how charting is done in the clinical setting. In preparing nurses for their role in maintaining accurate documentation, nursing education has assisted students in development of what one used to categorize as a “nurse’s note.” And yet, with technology comes great responsibility in helping to maintain both the accuracy and integrity of documentation in the clinical setting. Like other changes in education ranging from the transition of no longer teaching cursive writing, the “nurse’s note” has become part of the missing conversation in clinical practice. We will first focus on the historical aspect of the “nurse’s note,” then using a timeline approach enter the present day and finally consider what the future will hold for the “nurse’s note” in the 21st century and beyond.