1. Documentation Telana Fairchild Nurse Practitioner Students
UMass - Worcester,
Graduate School of Nursing
N/NG 603B

2. Types of Documentation
Narrative
Focused
Flow-sheet
By exception
Problem oriented
Narrative: Long paragraphs, no sections, nurse just explain pt in unformatted method. Hard to read, time consuming
Focused: DAR, data, action, response. Often times doesn’t include pt, lots of nursing diagnosis and doesn’t always tell the whole picture
Flow-sheet: Often found in the inpatient setting, for frequent monitoring or assessments
By exception: new method since computer charting, it is considered within normal limits unless documented otherwise. Again inpatient setting or at least policy stating documentation done by exception
Problem Oriented:
Documentation
April 15, 2013

3. Problem Oriented Effective among health care team
Includes patients input
Easy to read/follow
PIE: Problem, Intervention, Evaluation
SOAP/ER/IER: Subjective, Objective, Assessment, Plans, Interventions, Evaluation, Revisions
gives emphasis to client’s perceptions of their problems
requires continuous evaluation and revision of the care plan
provides greater continuity of care among health-care team members
enhances effective communication among health-care team members
increases efficiency in gathering data
provides easy-to-read information in chronological order
reinforces use of the nursing process
Documentation
April 15, 2013

4. SOAPIER Subjective: “pt statement” c/o
Objective: Nurses assessment, VS, General appearance
Assessment: Identify problems
Plan: Solutions to problems
Intervention: Agreed Solutions to try
Evaluation: Did it work?
Revision: New Intervention
Subjective the client’s observations usually what the client says after saying how are you today, etc
Objective the care provider’s observations, general appearance, behavior, attitude, your assessment, vs
Assessment the care provider’s understanding of the problem, based on subjective and objective data
Plans goals, action, advice
Intervention when an intervention was identified and changed to meet client’s needs
Evaluation how outcomes of care are evaluated
Revision when changes to the original problem come from revised interventions, outcomes of care
Documentation
April 15, 2013

5. References:
College and Association of Registered Nurses of Alberta. (2006). Documentation guidelines for Registered Nurses. College and Association of Registered Nurses of Alberta, Edmonton, AB. Retrieved from: %20Nurses.pdf
Scott, R.W. (2006). Legal Aspects of Documenting Patient Care for Rehabilitation Professionals (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers.
South Carolina Department of Disabilities and Special Needs. (2006). Nursing documentation guidelines. Retrieved from: NursingDocumentation.pdf
Documentation
April 15, 2013

6. What questions do you have?6
Documentation
April 15, 2013