Different Types of Nursing Documentation Methods

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Different Types of Nursing Documentation Methods

There are two categories of documentation methods in nursing such as documentation by inclusion and documentation by exception. In the former, nurse practitioners make note of all assessment findings, nursing interventions and client outcomes on an ongoing, regular basis. In the latter, they make note of negative findings and this documentation is completed when review findings, nursing interventions or client outcomes show a variation from the established assessment norms / standards of care prevailing in a particular practice setting. The common documentation methods in these categories are focus charting, SOAP charting and narrative charting. Nurse practitioners can select any of these methods, but ensure that the selected method reflects client care needs and the context of practice.

Focus Charting This documentation method focuses on particular client concerns/behaviors, a change in the client’s condition/behavior, or a significant event in the client’s treatment determined during the assessment. In the documentation, three columns are utilized for focus charting or F-DAR charting such as:

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Date and Hour – The relevant date and time are added here (for example, 20/10/2014, 7.30pm)

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Focus – This represents focus of care, which may be a current concern or behavior of the client, a change in a client’s condition or behavior or a significant event in the client’s treatment (for example: pain, hyperthermia)

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Progress Notes – These are organized into Data, Action and Response, which is referred to as DAR format.

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Data (D) – This is the assessment phase of the nursing process which includes subjective and/or objective information that supports the focus stated on the chart or describes the client status during the time of a significant event or intervention (for example, if the stated focus is pain, then the practitioner should note down what type of pain, the location of pain and how patient feels under Data).

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Action (A) – This represents the planning and implementation phase of the nursing process where completed or planned nursing interventions based on the assessment of the client’s status is described (for example, medicines, advices, exercises). Changes to the plan of care are also included in this section.

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Response (R) – This section is the evaluation phase of the nursing process in which the impact of the interventions on client outcomes is described (for example, if pain is the focus, then the observation whether pain is relieved or not is mentioned under Response)

Flow sheets and checklists are often used as an adjunct in order to document routine and ongoing assessments as well as observations including vital signs, personal care, etc. It is not required to repeat the information noted down on flow sheets in the progress notes.

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SOAP Charting SOAP charting uses a problem-oriented approach to documentation in which nurses first identify and list out patients’ problems and documentation is done on the basis of identified problems. This type of documentation is typically organized in the following manner: 

Subjective (S) – Nurses document how the patient actually feels in this section such as symptoms, patients’ complaints, medication side effects and so on. The patient’s own words are used as much as possible.

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Objective (O) – This section represents objective data including results of the physical exam, vital signs, lab results and studies.

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Assessment (A) – In this section, the patient’s status such as the diagnosis, prognosis, treatment, and side effects is documented along with the patient profile (age, sex, occupation, martial status and significant characteristics)

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Plan (P) – The medication strategy, planned tests and discharge plans are documented in this section. The section also discusses whether the plan stays the same or whether any changes are needed.

Flow sheets and checklists are used frequently as an adjunct along with SOAP charting.

Narrative Charting In this method, the patient’s status, nursing interventions and patients’ responses to those interventions are documented in chronological order covering a specific time frame. This information is typically included in progress notes and is supplemented by other tools including flow charts and checklists. It is required to document the patient assessments whenever the institution demands and more frequently when the following things are observed.

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Change in the patient's condition

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Patient’s response to a particular treatment or medication

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No improvement in the patient's condition

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Patient’s or family member's response to teaching

It is required to document what you hear, observe, inspect, do or teach along with specific descriptive information as much as possible. You should also include notification to the physicians if changes occurred. The physician’s response, new orders that need to be followed and the patient’s response should be documented as well. You can use a head-to-toe approach to organize your notes or you can refer to the care plan and document the patient’ progress with respect to the plan and any unresolved problems.

Whichever documentation method you select, make sure that it reflects client care needs and the context of practice. Certain institutions may combine elements of different documentation methods and formats. There should

be a standard

documentation procedure within the healthcare institution and if the institution changes its method or format, it should be done within the context of appropriate planning, involvement of nurses and their education. Accurate and standard documentation improves the communication between physicians and nurses, promotes good nursing care and helps to meet professional and legal standards.

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