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?

The correct answer is b. Misunderstanding of roles.

Choice A: Scope of practice

Reason: While the scope of practice defines the roles and responsibilities of different healthcare professionals, it is not inherently a barrier to interprofessional communication. Instead, it provides clarity on what each professional can and cannot do, which can actually facilitate better teamwork and communication.

Choice B: Misunderstanding of roles

Reason: Misunderstanding of roles is a significant barrier to interprofessional communication. When team members are unclear about each other’s roles and responsibilities, it can lead to confusion, overlap, and gaps in care. This misunderstanding can hinder effective collaboration and communication, as team members may not know who to turn to for specific issues or may duplicate efforts.

Choice C: Privacy laws

Reason: Privacy laws, such as HIPAA in the United States, are designed to protect patient information. While they impose certain restrictions on information sharing, they are not a primary barrier to interprofessional communication. Healthcare teams can still communicate effectively within the boundaries of these laws by ensuring that patient information is shared appropriately and securely.

Choice D: Burnout

Reason: Burnout is a significant issue in healthcare, affecting the well-being and performance of healthcare professionals. However, it is more of a personal and systemic issue rather than a direct barrier to interprofessional communication. Burnout can indirectly affect communication by reducing the overall effectiveness and engagement of team members.

Choice A: This is the correct answer. An electronic health record (EHR) is a digital version of a client's medical history and other health information that can be accessed by authorized providers and the client. A personal health record (PHR) is a subset of an EHR that allows the client to view and manage their own health information, such as medications, allergies, test results, and appointments. A PHR can enhance the client's satisfaction, engagement, and empowerment in their health care.
Choice B: This is incorrect. Provides providers client information to track for research studies is not a benefit of an electronic health record, but a potential use of it. EHRs can facilitate health research by providing large and diverse data sets that can be analyzed for various purposes, such as clinical trials, epidemiology, and quality improvement. However, this use of EHRs must comply with ethical and legal standards, such as informed consent, privacy, and confidentiality.
Choice C: This is incorrect. Grants significant other access to client information is not a benefit of an electronic health record, but a matter of the client's preference and consent. EHRs must protect the client's privacy and confidentiality rights, and only disclose their information to authorized parties, such as health care providers, insurers, or public health agencies. The client can choose to share their information with their significant other or anyone else, but they must give explicit permission to do so.
Choice D: This is incorrect. Coordinates all healthcare client has received into one platform is not a benefit of an electronic health record, but a goal of it. EHRs aim to improve the coordination and continuity of care by allowing multiple providers to access and update the same information, enabling real-time collaboration, and providing decision support tools. However, this goal is not fully achieved yet, as there are still challenges and barriers to the interoperability and integration of EHRs across different settings and systems.