Methods Of Recording /

Documentation Systems BY:

Mr. M.Shivananda Reddy

• There are several documentation systems for

recording patient data.

• Regardless whether documentation is entered

electronically or on paper, each health care

agency selects a documentation system that

reflects its philosophy of nursing.

Methods (styles) of documentation:

• Narrative Charting• Source-Oriented Charting• Problem-Oriented Charting• PIE Charting• Focus Charting• Charting by Exception (CBE)• Computerized Documentation• Case Management with Critical Paths

• Narrative Charting

– Describes the client’s status, interventions and treatments; response to treatments is in story format.

– Narrative charting is now being replaced by other formats.

• Source-Oriented Charting

– Narrative recording by each member (source) of the health care team on separate records.

– For example the admission department has an admission sheet, nurses use the nurses’ notes, physicians have a physician notes, etc….

• Problem-Oriented Charting

– Uses a structured, logical format called S.O.A.P.• S: subjective data• O: objective data• A: assessment (conclusion stated in a form of

nursing diagnoses or client problems)• P: plan

Recently S.O.A.P. format is modified as S.O.A.P.I.E.R for better reflecting the nursing process

• S: subjective data• O: objective data• A: assessment (conclusion stated in a form of nursing

diagnoses or client problems)• P: plan

.I – intervention (specific interventions implemented) .E – evaluation. Pt response to interventions.

.R – revision. Changes in treatment.

• PIE Charting

– P: Problem statement – I: Intervention– E: EvaluationExample:– P: Patient reports pain at surgical incision as 7/10 on 0 to 10 scale – I : Given morphine 1mg IV at 23:35.– E : Patient reports pain as 1/10 at 23:55.

• Focus Charting

– A method of identifying and organizing the narrative documentation of all client concerns.

– Uses a columnar format within the progress notes to distinguish the entry from other recordings in the narrative notes (Date & Time, Focus, Progress note)

– The progress notes are organized into: Data (D), Action (A), Response (R).

• DATA – SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN)

• ACTION – NURSING INTERVENTION

• RESPONSE – PT RESPONSE TO INTERVENTION

. Date & Time Focus: Progress notes:

09.june.2015 Acute pain related to surgical incision

D: Patient reports pain as 7/10 on 0 to 10 scale. A: Given morphine 1mg IV at 23.35. R: Patient reports pain as 1/10 at 23.55

• Charting by Exception (CBE)

– The nurse documents only deviations from pre-established norms (document only abnormal or significant findings).

– Avoids lengthy, repetitive notes.

• Computerized Documentation

– Increases the quality of documentation and save time.

– Increases legibility and accuracy.

– Facilitates statistical analysis of data.

• Case Management Process

– A methodology for organizing client care through an illness, using a critical pathway/ standardized care plan.

– A critical pathway is a multidisciplinary plan or tool that specifies assessments, interventions, treatments and outcomes of health related problems a cross a time line.