Lesson 1, Topic 1
In Progress

Methods of Recording

May 1, 2021

The documentation system selected by a health care facility optimally reflects the philosophy of the facility and the way nursing care is implemented. Professionally executed charting is legal proof of care given and communicates the patient’s status and progress. The nursing process shapes the approach to providing care, and in turn, effective documentation of the care the nurse provides reflects the nursing process.

Traditional Chart

The traditional (block) chart is divided into sections or blocks. Emphasis is placed on specific sections (or sheets for non-computerized charts) of information. Typical sections are the following: admission information, physician’s orders, progress notes, history and physical examination data, nurse’s admission information, care plan and nursing notes, graphics, and laboratory and x-ray examination reports. The order, the content, and the number of the sections vary among institutions. Nurses use flow sheets, graphics, and narrative charting (recording of patient care in descriptive form) (Figure 3-2) to chart observations, care, and responses. Narrative charting is used for both computerized and non-computerized nurse’s notes. Narrative charting includes the data (subjective, objective, or both) about the basic patient need or problem, whether anyone has been contacted or consulted, care and treatments provided (implementation), and the patient’s response to treatment (evaluation). Information obtained from the nurse’s assessment of the patient is clustered (see Chapter 5) and organized in a head-to-toe manner. This type of charting is documented in an abbreviated story form instead of in the outline style of the problem-oriented medical record (POMR) format described in the following section.

Problem-Oriented Medical Record

The problem-oriented medical record is organized according to the scientific problem-solving system or method. The principal sections are database, problem list, care plan, and progress notes. The accumulated data, or database, from the history, the physical examination, and the diagnostic tests are used to identify and prioritize the health problems on the master medical and other problem list.

This problem list (Figure 3-3) of active, inactive, potential, and resolved problems serves as the index for chart documentation. Together, representatives of all the disciplines involved with the patient’s care develop a care plan with nursing diagnosis for each problem (Figure 3-4). All health care providers—physicians, nurses, social workers, and therapists—chart on the same progress notes with forms such as narrative notes, flow sheets, and discharge summaries to document patient progress. This is done to facilitate and enhance communication between care providers.
SOAPIER (SOAPE documentation) (Box 3-3) is an acronym for seven different aspects of charting. For notes on specific patient problems, only the necessary parts needed for completeness are used.

S Subjective information is what the patient states or feels; only the patient can provide this information.
O Objective information is what the nurse can measure or factually describe.
A Assessment refers to an analysis or potential diagnosis of the cause of the patient’s problem or need.
P Plan is the general statement of the plan of care to be given or action to be taken.
I Intervention or implementation is the specific care given or action taken.
E Evaluation is an appraisal of the response and effectiveness of the plan.
R Revision includes the changes that may be made to the original plan of care.

SOAPE is the briefer adaptation of the charting format for the POMR. In this more compact form, the care given or action taken (intervention [I]) is included in the notations under planning. The needed plan revisions (R) are noted in the evaluation section after the evaluation of the response to treatment is recorded. Figure 3-5 shows the SOAPE charting forms in the progress notes that are commonly used in the patient’s medical record.

Focus Charting Format

In the focus charting format (Box 3-4), which was developed by nurses, a modified list of nursing diagnoses is used as an index for nursing documentation instead of problem lists. Note the similarity of this list to the problem list used for the POMR. Focus charting can be used with both traditional and POMR charting.
Focus charting uses the nursing process and the more positive concept of the patient’s needs rather than medical diagnoses and problems. The focus is sometimes a current patient concern or behavior and sometimes a significant change in patient status or behavior or a significant event in the patient’s therapy. A focus is not a medical diagnosis.
DARE is the acronym for four different aspects of charting using the focus format (see Box 3-4). Data (D) is both subjective and objective and is equivalent to

the assessment step of the nursing process. Action (A) is a combination of planning and implementation. Response (R) of the patient is the same as evaluation of effectiveness. Some facilities include education or patient teaching (E). The nurse does not need to use all the DARE steps each time notes are documented on a particular focus (Figure 3-6).

Charting by Exception

Some facilities require the narrative notes for each shift to include a minimum of three entries, and a flow sheet on which the nurse charts care given. Behind this policy is the legally derived charting concept that if the care was not documented it is considered that care was not provided. All care has to be charted, but this is a time-consuming, detailed, and defensive manner of doing so.

To get around this problem, many facilities now have a policy called charting by exception (CBE). The nurse charts complete physical assessments, observations, vital signs, intravenous (IV) site and rate, and other pertinent data at the beginning of each shift. During the shift, the only notes the nurse makes are for additional treatments done or planned treatments withheld, changes in patient condition, and new concerns. Notations are made reflecting progress or revisions for all active nursing diagnoses on the nursing care plan.

With the CBE method of documentation, the nurse uses more detailed flow sheets, which enhances the focus on existing concerns. One format that may be used is the problem, intervention, and evaluation (PIE) format. In that it is a problem-solving approach, PIE is similar to the SOAPE format; the main difference is that SOAPE charting originated from the medical model, whereas PIE charting arose from the nursing process. The SOAPE method of documentation is also oriented to the problems, interventions, and evaluations involved in nursing care. It was designed to provide an ongoing plan of nursing care with daily documentation. The care and assessment flow sheets consist of standardized assessment criteria and interventions. With this method, the nurse assesses all areas and compares the results with normal standards.

The PIE format may be written in several ways so the nurse should use the format dictated by the agency’s policy. At each shift, the nurse evaluates each patient problem at least once, and if the problem remains unresolved, the nurse ensures it is continuously addressed until resolution is reached. After the patient problem is resolved, it is no longer covered by the daily documentation.

Sometimes the nurse uses a variation of the PIE format that includes assessment (A) data before the PIE (APIE). This assessment data includes both subjective (S) and objective (O) data. This assists the nurse to follow the steps of the nursing process (Figure 3-7).

Record-Keeping Forms and Examples

Different facilities use a variety of forms to make medical record documentation easy and quick, yet comprehensive. Many forms help eliminate the need to duplicate data repeatedly in the nursing notes. The forms present several types of information in a format more accessible than compilation of all progress notes. Most of the forms are self explanatory as to the type of information required from the nurse (Figure 3-8). It is unnecessary to chart a narrative note each time a medication is given (see Chapter 21) or a bath (see Chapter 9) or measurement of vital signs (see Chapter 11).

The nursing Kardex (or Rand) system is a system used by some facilities to consolidate patient orders and care needs in a centralized concise way. The cumulative care file or Rand is kept at the nursing station for quick reference or is part of the EHR or EMR. Forms vary among institutions based on information required for care (Figure 3-9).

The nursing care plan (plan that outlines the proposed nursing care based on the nursing assessment and nursing diagnoses to provide continuity of care) is developed to meet the nursing care needs of a patient. Many facilities use standardized care plans for certain conditions or surgeries; however, individualization of the plan of care based on each patient’s own needs or circumstances is also important. This kind of plan, developed by nurses for nurses, is based on nursing assessment and nursing diagnosis. Standardized nursing care plans include the pertinent nursing diagnoses, goals, and plans for care and specific actions for care implementation and evaluation.

Incident Reports

An incident report (form used to document any event not consistent with the routine operation of a health care unit or the routine care of a patient) (Figure 3-10) is sometimes necessary in response to an unplanned occurrence within a health care facility. For example, if a nurse neglects to give a medication or treatment or gives an incorrect dose of a drug, an incident report must be filed. Either of these events has the potential to cause injury. Incident reports are also filled out for any unusual event in a hospital (e.g., injuries to a patient, visitor, or hospital personnel). Many staff members are reluctant to fill out these forms, but this information helps the facility risk manager and unit managers to track occurrences of incidents. One of the benefits of tracking particular incidents is to prevent future problems through education and other corrective measures.

When filling out an incident report, the nurse should give only objective, observed information. The nurse should not admit liability or give unnecessary details. Care given to the patient in response to the incident and the name of the health care provider notified should be included in the incident report. When charting the incident in the patient’s nursing notes, the nurse should not mention the incident report because doing so makes it easier for an attorney to request that document for a court case (Table 3-3).

Twenty-Four–Hour Patient Care Records and Acuity Charting Forms

The nursing records may be consolidated into a system that accommodates a 24-hour period. A 24-hour record-keeping system helps eliminate unnecessary record-keeping forms. It is easier to obtain accurate assessment information and documentation of activities of daily living with 24-hour notations. In addition, 24-hour patient care records often use flow sheets and checklists to further enhance efficiency.

Twenty-four–hour patient care records provide the foundation for an acuity charting system. Acuity charting uses a score that rates each patient by severity of illness. With documentation and analysis of nursing interventions, an overall level of acuity for each patient is determined. For example, perhaps an acuity system rates patients from 1 to 5 (1 is high, 5 is low). A patient returning from surgery with multisystem problems is an acuity level 1. On the same continuum, another patient awaiting discharge after a successful recovery from surgery is an acuity level 5. One benefit is the ability to determine efficient staffing patterns according to the acuity levels of the patients on a particular nursing unit. The patient-to-staff ratios depend on a composite gathering of data in regard to the 24-hour interventions necessary for implementing care.

Discharge Summary Forms

Much emphasis is placed on preparing a patient for a timely discharge from a health care institution. Ideally, discharge planning begins at admission, and in some cases, even before admission, as is necessary with same-day surgery admissions and childbirth. Nurses continue discharge planning as the patient’s condition changes. Patients and family should be involved in the discharge planning process.

A discharge summary form provides important information that pertains to the patient’s continued health care after discharge. A discharge summary should always be provided to the patient or the family (or both) so there is written documentation of instructions

given to the patient and so that the patient can refer back to those instructions after being discharged. Discharge summary forms (see Figure 13-6) make the summary concise and instructive. Often, the form includes a copy that is given to the patient, a family member, or a home health care nurse and a copy that is kept with the patient records. Home health care agencies or extended nursing care facilities also benefit from receiving information on these summary forms and use it to provide better continuity of care.