Methods for Documenting Nurses Notes
(Nursing Documentation and Charting)
Narrative: The nurse may be asked to chart in chronological order the events that occur including the gathering of information. A sentence structure is usually preferred although the use of columns to organize the narrative may be used. There may be a separate column for treatments, nursing observations, comments, etc. Narrative charting is time consuming, so legibility is extremely important if the notes are to be understood by those reading them.
SOAP: This is an acronym for Subjective data, Objective data, Assessment, and Plan. Some facilities use the acronym SOAPIE in which Implementation (nursing actions or interventions) and Evaluation have been added. And then, there is SOAPIER in which Revision is the last component. Following each letter of the respective acronym used, the nurse is required to chart information relevant to that particular term.
APIE: This is a more recent method which requires the nurse to includeAssessment, Plan, Implementation and Evaluation. It is a method, which condenses client data into fewer statements by combining subjective and objective data into the Assessment section and combining nursing actions (what the nurse will do) with the expected outcomes of client care (what the client will get or experience) into the Plan component.
PIE: This is an acronym for Problems, Intervention and Evaluation of nursing care. The system consists of a 24-hour flow sheet combined with nursing progress notes. The notes are usually written as client problem statements using an approved nursing diagnosis. Problems are labeled "P" and given a number, nursing interventions are labeled "I" and evaluations of the nursing action or intervention are labeled "E."
Flow Sheets: These are often called "graphic records" and are used as a quick way to reflect or show the client's condition. They are helpful records in documenting things such as vital signs, medications, intake and output, bowel movements, etc. The time parameters for a flow sheet can range from minutes to months. For example: In an intensive care unit a blood pressure might be recorded every 5 minutes while in a clinic setting a weight may be recorded only once a month.
Focus Charting: The term focus was coined to encourage nurses to view the client's status from a positive perspective rather than the negative focus in problem charting. The system uses three (3) columns as indicated here. Note the information that is usually required in the third column titled Progress Notes (called the DAR):
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Charting By Exception (CBE): This is a system of charting in which only significant findings or exceptions to standards or norms of care are recorded or charted. Flow sheets or charts are used in which check off marks are recorded. Recording an asterisk (*) means that a standard or norm of care was not implemented. The asterisk (*) also means that a narrative nurses note has been charted to explain why the standard of care was not met or satisfied.
Regardless of the system of documentation that is used, nurses universally use or refer to the Nursing Process as a guideline when they are charting. The Nursing Process contains the following four (4) phases of nursing care:
1. Assessment: observing the client for signs and symptoms that may indicate
actual or potential problems.
2. Planning: developing a plan of care directed at preventing, minimizing or
resolving identified client problems or issues.
3. Implementation: practicing the plan of care that has been developed; includes
specific actions that the nurse needs to take to activate that plan.
4. Evaluation: determining whether the plan of care was effective in preventing,
minimizing or resolving identified problems.
FACT Documentation System: The computer ready FACT system incorporates many CBE principles; it helps caregivers avoid documenting irrelevant information or repetitive notes and reduces the time spent in charting. The FACT format uses:
An assessment and action flow sheet: to document ongoing assessments and actions; normal assessment parameters for each body system are printed on the form along with planned actions. You can individualize the flow sheet according to your specific patient's needs.
A frequent assessment flow sheet: this is where you document vital signs and frequent assessments. On a surgical unit, for example, you would use a postoperative frequent assessment flow sheet.
Progress notes: require an integrated progress record; you would use narrative notes to chart the patient's progress and any significant events. As in FOCUS charting mentioned before, you would use the data-action- response method of charting.
SOURCE: http://www.corexcel.com/html/body.documentation.page8.ceus.html
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