Methods Of Nursing Documentation Prepared by -:

Taghreed hamza hawsawi RN –BSN

Nursing Educator

Outline -:

• Introduction • Method of documentation a. Narrative documentation b. Problem-Orientated Medical Record (POMR) c. SOAP/IER D . The PIE notes e. Focus Charting • Nursing diagnosis • Reference .

Introduction -:

Documentation is not separate from care and it is not optional. It is an integral part of registered nurse practice, and an important tool that RNs use to ensure high-quality client care.

The term “documentation” refers to: any written or electronically generated information

about a client that describes client status or the care or services provided to that client.

Method of documentation -:

Narrative documentation :- is the traditional method for recording nursing

care provided. It is a story-like format to document information specific to client conditions and nursing care.

Data are recorded in the progress notes without an organizing framework. It often requires the reader to sort through information to locate the data required.

Guidelines -: 1. the initial entry and assessment, narrative notes include all

patient care activities such as diet, hygiene, ambulation, elimination, visits from health care professionals (Dr, dilatation, social worker , etc) or family, tests, specific problems

2. All entry are signed and dated. Every timed entry must have a legal signature: 1st initial, last name and legal status.

3. The last entry on a page must have a legal signature. Plan the last entry on a page so it has a logical statement and signature.

4. Each page of narrative notes is a legal document must be dated–and signed.

POMR

Problem-Orientated Medical Record (POMR) Recording data abut the health status of a

patient I a problem solving system the POMR preserves the data in an easily accessible way that encourage ongoing assessment and revision of the health care plan by all members of health care team .

All data base is collected before beginning of identifiying the patient problem .

General concepts

• 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

SOAP/IER -: SOAP/IER One of the most prominent features of this problem-orientated

method of documentation is the structured way in which narrative progress notes are written by all health-care team members, using the SOAP, SOAPIE or SOAPIER format

Subjective the client’s observations

Objective the care provider’s observations and tests

Assessment the care provider’s understanding of the problem

Plans goals, action, advice

SOAP/IER -:

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 or time lines this is used to denote changes

: -PIE

The PIE notes are numbered or labeled according to the client’s problems. Resolved problems are dropped from daily documentation after the RN’s review. Continuing problems are documented daily (Potter et al., 2006 )

Problems

Intervention

Evaluation

Focus Charting -:

Focus Charting (sometimes referred to as DAR) This method of documentation consists of notes that include data, both subjective and objective; action or nursing interventions; and response of the client.

Data

Action

Response

Type of Diagnosis

physical diagnosis differential diagnosis medical diagnosis clinical diagnosis

diagnosis based on information obtained by inspection, palpation,

percussion, and auscultation

the determination of which one of several

diseases may be producing the

symptoms

diagnosis based on information from sources such as findings from a

physical examination,

interview with the patient or family or

both, medical history of the

patient and family, and clinical findings

as reported by laboratory tests and

radiologic studies

diagnosis based on signs, symptoms,

and laboratory findings during life

Definition -:

• a statement of a health problem or of a potential problem in the client's health status that a nurse is licensed and competent to treat.

• The process of assessing potential or actual health problems, including those pertaining to an individual patient, a family or community, that fall within the scope of nursing practice; a judgment or conclusion reached as a result of such assessment or derived from assessment data.

Type of nursing diagnosis -: 1- ACTUAL: It’s referred to the recent problem that the patient is

complaining from it .

Example: Impaired gas exchange r/t status of secretions associated with difficulty coughing up secretions from fatigue .

1. Large amounts thick green-yellow sputum 2. Frequent coughing with expectoration of sputum 3. Crackles throughout both lung fields 4. O2 sat of 90 - 87% without oxygen

Type of nursing diagnosis -:

RISK: This diagnosis indicates from the data, a strong

likelihood that it will occur if actions are not taken.

The Risk diagnosis only has 2 parts. It can be used with any NANDA diagnosis.

Example: Risk for falls r/t to unsteady gait

Type of nursing diagnosis -: POTENTIAL COMPLICATION: This is also known as a collaborative diagnosis. This is a problem

the nurse cannot treat independently. Nursing care will focus on monitoring and preventing the problem.

A collaborative diagnosis can be written as a one or two part statement.

Example: P.C. of chronic obstructive pulmonary disease: respiratory

failure

REFERENCES -:

• CRNBC Practice Standard Documentation• www.crnbc.ca/NursingPractice/Requirements.aspx• Meadows G. Nursing informatics: An evolving

speciality. Nursing Economic$ 2002;20(6):300–301. [PubMed]