@inproceedings{oai:tau.repo.nii.ac.jp:00000033,
 author = {北島, 泰子 and 山下, 雅子 and 前田, 樹海 and 辻, 由紀 and KITAJIMA, YASUKO and YAMASHITA, MASAKO and MAEDA, JUKAI and TSUJI, YUKI},
 book = {医療情報学, Japan journal of medical informatics},
 issue = {Suppl.},
 month = {},
 note = {The purpose of this study was to explore factors of weakness in nurses' use of the SOAP format on the nursing record in their daily nursing service. In addition, to propose an idea for an optimum method for keeping nursing records. The structure of the SOAP format was set up to utilise extraction of problems style. Subjective Data or Objective Data were unable to function in isolation due to underived Assessment and Plan. However, information of isolation data can sometimes signal a serious problem or mean something.

We researched the 25 nurses working in a unit of a hospital, and asked them whether they had had an experience of discarded information actually turning out to be of importance. In one instance, a nurse gave attention to the behavior of one
patient, though it was difficult to record by use of the SOAP format on the nursing record. Afterward that patient became fatal, so that the behavior of the patient at that time was of significance for later.

The SOAP format was superior in terms of enabling the record of nurse's observations and thinking to be written briefly. At the same time it was fraught with possibilities of loss of key information. It is getting even more complicated if nurses have to record the patients' data all of the time in chronological order. Electronic health record system has increased in the past few decades. It is suggested that by use of Folding mode and Development mode of electronic health record system it may become almost possible to create a clear, concise and detailed record.},
 pages = {636--639},
 publisher = {日本医療情報学会},
 title = {看護記録の内容の煩雑化回避と情報網羅の両立に向けて},
 volume = {35},
 year = {2015},
 yomi = {キタジマ, ヤスコ and ヤマシタ, マサコ and マエダ, ジュカイ and ツジ, ユキ}
}