Fundamentals of Nursing
Chapter 5: Documentation
1. Purposes of documentation
a. Documentation: the act of recording pertinent medical info in a pt’s medical record;
may be handwritten on a paper chart or typed into an electronic medical record
b. Continuity of Care
i. It is the nurse’s responsibility to doc all pertinent pt data 24 hours a day.
ii. Doc helps to provide physicians and other members of the health-care team
with a complete pic of each pt’s individual problems, tx, and responses to tx.
iii. For pt care to be effective, it must be delivered and evaluated continuously,
systematically, and smoothly from 1 hour to the next, inc thru staffing changes
b/w shifts.
iv. Must comm pt’s current condition, changes, care given and its effectiveness,
and meds that have been given and their effectiveness, + care to be delivered in
the oncoming hours.
v. Written doc = source of info that can be used to make decisions on care to be
given
c. Permanent Record of Care
i. Doc helps produce a permanent record of pt’s condition, diagnoses, results of
diagnostic tests and procedures that were done, and care that was provided, +
pt’s outcome.
ii. Supplies a perm source of medical hx that can be ref’d if pt needs care in the
future.
iii. Allows for future comparison of phys assessments, illnesses, injuries, or test
results w those from the past
iv. Allows for detection of changes that may have occurred.
d. Accountability
i. Medical records/Charts, used by facility QA committees to monitor quality of
care.
ii. Help facilities to detect problems, negative outcomes, areas of weakness so
improvements can be made.
iii. Stats, such as rates of HAIs, mortality rates, success rates of procedures, and #
of incidents/accidents; are defining factors of a facility’s rep.
iv. Govt and other accrediting agencies, such as The Joint Commission, also audit
medical records to verify compliance in meeting standards.
1. Joint Commission (TJC) sets the standards by which the quality of health
care is measured, both nationally and internationally.
2. Seeks to improve the safety and quality of the care.
3. To be accredited by TJC, facility must meet TJC’s standards. Determined
by a team of reviewers who visit the facility to assess.
v. Reimbursement by insurance companies/third-party payers depends on doc of
spec data in record, correct doc = financial survival for facilities.
vi. Researchers also use data from records in experimental work and development.
e. Legal Record
i. Safety: From a legal standpoint, it is best to assume that if it wasn’t charted, it
wasn’t done.
ii. Not Charted, Not Done
1. The phrase “Not charted, not done” is interpreted to mean that if
something is not documented, then it was not done or did not occur.
2. This is inherently false if the documentation method is charting by
exception, which limits charting to only abnormal findings, situations,
conditions, or results.
3. The phrase “not charted, not done” may be used against you when you
forget to chart something that is, or later turns out to be, pertinent.
4. Documentation that is lacking in full detail serves to support even false
claims of negligence or malpractice.
5. Lawsuits often are not filed until years after the precipitating event.
6. Documentation is recognized as written evidence.
iii. Whose Medical Record Is It?
1. The record is the property of the hospital or facility.
2. In a physician-owned medical office, the record is the property of the
physician.
3. All the info in the chart belongs to the patient. The pt has the right via
HIPAA to view and obtain a copy of record, but pt doesn’t have the right
to take the original chart copy itself.
4. HIPAA ensures pt’s right to view and copy their own record but also to
amend their own health info.
5. HIPAA requires facilities to disclose to each pt, in writing, the way the
pt’s health data will be used and to ask them to specify who can obtain
their PHI.
6. You are responsible to know your facility’s policy and procedure
regarding this issue.
7. For EHRs, HITECH extends the HIPAA regulations for pt privacy and
disclosure of PHI.
8. HITECH est requirements for notifs if privacy has been breached.
9. Safety: Never allow anyone to access the chart until you have verified
the facility’s policy and ensured that the patient has granted consent in
writing.
2. Confidentiality of documentation
a. Confidentiality: the maintenance of privacy by not sharing with a third party privileged
or entrusted info. Violated when personal info is provided to another person w/o pt’s
permission or knowledge. This can lead to litigation.
b. All medical records must be protected and maintained so no unauthorized ppl have
access to them, only the hcp that are directly involved in the pt’s care
c. Before ur allowed to send records even to another doc who the pt is being referred to,
pt must sign a written consent
d. Safety: Remember u can’t confirm that an individual is a pt in your facility without
specific permission from the pt.
e. Safety: Take care to avoid leaving pt care notes, lab results, MARs, and pt charts lying
open and accessible to other facility employees and the public.
f. Safety: Any handwritten notes or copies of confidential pt info should be shredded after
their purpose has been fulfilled.
g. Safety: Just before faxing the medical record, call the recipient to inform him or her of
the impending confidential fax.
3. Uses of documentation forms
a. Report Form
i. The notes u take during shift report should be detailed and serve as ur template
for scheduled duties for the coming shift, if this is not provided on a printout.
This form will need specific areas to document the following:
1. Room number; pt name, age, weight, and sex; and attending physician
2. Date of admission and diagnoses
3. Frequency of vital signs and activity orders
4. Type of diet ordered, NPO status, fluid restrictions, IV, or I&O totals
5. Any diagnostics to be done and pertinent results of recent tests
6. Personal care that may be needed
7. All nursing care to be delivered
ii. Safety: The ideal method to ensure documentation accuracy is to consistently
chart immediately after care is provided, after assessment data are obtained,
and after any event or occurrence that has the potential to affect the pt.
iii. You can write a quick note at the bedside or outside the pt’s door, w specific
times and data that can be put in the chart asap.
iv. Memories are fallible when we’re trying to keep track of dozens of facts abt
multiple pts. Excessive stimuli < ppl’s ability to recall details.
v. Pt’s improvement, even their life, may depend on the accuracy of ur doc.
vi. Accuracy of the time at which things occur and the tasks that are performed can
be momentous in regard to legal action.
b. Incident Reports
i. Another type of documentation that isn’t part of the pt’s record is the incident
report AKA variance report. Used to document abnormal things that happen in a
facility.
ii. Incident may or may not actually involve a pt.
iii. Things that should be documented on an incident report form include:
1. Medication error
2. Patient injury
3. Visitor injury
4. Employee injury
5. Condition constituting a safety hazard, such as an unsafe staffing
situation or failure to repair reported broken or damaged equipment
6. Failure of appropriate health-care provider response to an emergency
7. Failure to perform ordered care
8. Loss of patient’s personal belongings, prosthetic or assistive devices,
home medications, or secured valuables
9. Lack of availability of vital patient care supplies or equipment
iv. The report is designed to protect the facility, you, and the pt when something
unusual occurs by providing accurate facts regarding the incident or occurrence.
v. Be objective, put only what you were able to detect w ur senses—what you saw,
heard, smelled, or were able to feel with your hands. Avoid interpreting.
vi. Safety: Never document assumptions or drawn conclusions.
vii. Will include the incident and the action taken and any care provided after the
occurrence.
viii. Will have a section where u list any witnesses, the MD who was notified, orders
received, sig of employee involved/discovered the variance, supervisor’s sig.
ix. These reports are kept separate from pt records, and reviewed/analyzed by
facility committees.
x. Provides an accurate record of what happened for use if legal action results.
xi. Helps to identify unsafe conditions which a change in the facility’s policy may
prevent or reduce the risk for repeats.
c. Care Plans
i. A form of written documentation is the plan of care developed for each pt.
ii. Comms pt’s probs, interventions for each problem, effectiveness of them.
iii. Revisions to the plan of care are made and documented w/i the plan as the pt’s
changing condition warrants, providing a current action plan for HCPs to follow.
d. Patient Chart or Medical Record
i. The longest form of written doc is the pt’s chart or medical record.
ii. For computerized documentation, be sure to follow these guidelines:
1. Avoid taking charting shortcuts. DO NOT “copy and paste”
2. Avoid leaving blank spaces in the EHR. Use “N/A,” “denies,” or “not
observed” to complete lines rather than leave them blank.
3. Use only approved abbreviations.
4. Be accurate. Make sure all pertinent data is recorded. Be factual. Be
specific. Avoid using judgmental language. Don’t doc ur opinions,
assumptions, interpretations, or self-drawn conclusions. Refrain from
using subjective terms such as strange, well, average, normal, bad, poor,
odd, or good bc they’re vague.
5. Be objective.
a. Safety: Do not allow your perspective or your personal feelings
and emotions to be expressed in your documentation. Chart
only those objective data that you can detect with your senses.
b. What you can see, read, or observe with your eyes
c. What you can smell with your olfactory sense
d. What you can feel using your sense of touch
e. What u can hear w ur ears w or w/o a stethoscope, includes
subjective data that the pt, family, or their s.o may tell you
iii. The only subjective data that you will chart will be things that the pt, family, or
significant other tells you.
iv. When you chart direct quotations of the pt, you should use their exact words
and place them in quotation marks.
4. Types of medical records
a. Source-Oriented Records
i. Typical Sections of the Source-Oriented Medical Record
1. Organized according to the source or type of data, using specific forms
for each, with each section designated by a labeled tab.
2. The various HCPs and staff enter data under their corresponding tab.
3. While most other disciplines will make entries in only 1 or 2 sections, as
a nurse you will document in multiple sections of the chart.
b. Problem-Oriented Records
i. Problem-oriented records differ from source-oriented records in that they are
organized around the pt’s individual problems rather than where the data came
from, as in the source-oriented system.
ii. The problem-oriented medical record will have four primary sections:
1. Database
2. Problem list
3. Plan of care
4. Progress notes
iii. Additional forms, such as a flow sheet or discharge summary sheet, may be
used according to the facility’s policy.
iv. The advantage is that it encourages collab b/w all the disciplines providing care
to the pt.
v. Another advantage is that the list of pt problems is kept at the front of the
chart, where it is easily accessed. Bc all HCPs write their notes chronologically in
same section = quick retrieval of all entries regarding the pt’s responses to tx.
5. Data to document
a. Table 5.4: Sections of Problem-Oriented Medical Record
i. Database
1. Demographic data:
a. patient name
b. age
c. address
d. phone number
e. religious preference
f. next of kin
g. contact info
h. occupation and employer’s name and address
2. Personal identification data:
a. birth date
b. Social Security number
c. photo ID
d. insurance data
e. permission to treat and permission to disclose patient medical
data to insurance company and specified ppl
f. hospital id #
g. admitting medical dx
3. Assessments:
a. physician’s hx and physical
b. nursing’s initial assessment
c. results of diagnostic tests, incl lab tests and x-rays
4. Patient’s current condition
ii. Problem List
1. Made from info in database, a chronological (not prioritized) list of
potential and actual pt probs is developed
a. updated as probs resolve or worsen, or new probs appear
b. probs are numbered and kept at front of chart
c. the #s are used to reference the specific problem when making
an entry in plan of care or progress notes
iii. Plan of Care
1. For each listed prob: MD’s orders, nursing orders and plan of care, and
interdisciplinary interventions are listed, incl diagnostics, therapeutic
plan, and teaching
iv. Progress Notes
1. Organized according to prob list; all disciplines chart on same progress
notes, # each entry to correspond w prob list
b. Box 5.2: Specific Data to Be Charted by Category
i. Assessment
1. Initial shift assessment from beginning of shift to be used as baseline.
2. Abnormal assessment findings to be reassessed later in shift.
ii. Nutrition
1. Type of diet.
2. How much the patient eats
3. How was the diet tolerated
4. Did pt eat any snacks during the shift? If so, what/how much?
5. Is pt drinking enough fluids? Is pt on I&O? Was pt taught to record I&O?
iii. Hygiene
1. What type of bath was given
2. Did pt require assist, was pt able to bathe independently?
3. Was mouth care provided by you or performed by pt? How often?
4. Was a back rub performed?
5. Was hair care, nail care, shaving, or skin care done?
6. What was pt’s response to the hygiene?
7. Was pt’s skin clean, fresh, and intact?
iv. Activity Level
1. Is pt on bedrest, ambulatory w or w/o assist? If assist, # of ppl needed
to amb? Can pt only be gotten up for BRP or to sit in a chair?
2. ROM exercises performed? Active/passive? Which extremities, how
often?
3. Was pt logrolled? Hoyer lift? How did pt tolerate activity? Was pt SOB?
Did the pulse rate go up? Did knees buckle, did pt become unsteady?
v. Physician Visits
1. Did a physician see or examine the patient on your shift? If so, who?
2. Did MD remove clips from an incision? Were new orders written?
3. Did u have to call/comm data to MD? What info reported/orders rec’d?
vi. Elimination
1. Is pt continent/incontinent of bowel and/or bladder?
2. When was pt’s last bowel movement? Voiding?
3. What is the color, clarity, and amount (if on I&O) of urine?
4. Did pt have any complaints, such as burning or frequency?
5. If there is a Foley catheter, addl info must be noted as well
6. Color, amt, consistency of BMs? Pt complaints of gas, cramping?
7. Note: If there was no BM during your shift, a note indicating no BM
should be made at the end of the shift.
vii. Nursing Care (Implementation Step of Nursing Process)
1. Any care that you administer must be objectively documented
2. Includes patient teaching and discharge planning
viii. Patient’s Response to Interventions (Evaluation Step of Nursing Process)
1. How did the patient respond to your intervention?
2. There is always a pt response, and we must chart them.
ix. Safety Issues
1. Bed in a low position, the status of bed rails, suction machine available
at bedside, call light within reach, and use of Hoyer lift w 3 assists. Pt
instructions as to call for assist before getting out of bed, use of shower
chair, other interventions taken to keep the pt from harm.
x. Laboratory and Diagnostic Testing
1. Document when pt is taken to another department for tests or
treatments. Include how the patient was transported: Did the patient
walk, ride in a wheelchair, or go on a gurney? For example: “to radiology
via W/C for a CXR.” “Returned from MRI via gurney.”
xi. All Patient Complaints
1. Pain, nausea, dizziness, anxiety, fear, tingling, or itching, or that the pt
does not like the ordered diet.
6. Methods of recording patient information
a. Each EHR system has its own method for accessing an area for narrative charting, most
routine doc is done in a “select and click” format.
b. When addl doc is required, each facility has its own pref method for recording info
c. Table 5.5: Methods of Charting
i. SOAP/SOAPIER
1.
2.
3.
4.
5.
6.
7.
Can be used with source-oriented or problem-oriented records.
Subjective data
Objective data
Assessment data
Plan/Intervention
Evaluation
Revision
ii. PIE
1.
2.
3.
4.
5.
iii. Focus
1.
2.
Addresses pt’s probs & what is done to solve them.
Seen mostly in nurse’s notes.
Problem
Intervention
Evaluation
Focused on pt, less structured than PIE.
A common type is DAR:
a. Data
b. Action
c. Response
iv. Narrative
1. No set formula is followed; rather, HCP writes a detailed account of the
care pt receives and events that occur in chronological order
2. Most thorough but most time-consuming type of documentation
v. Charting by Exception
1. Notes written by HCPs that focus only on abnormal findings; normal
findings are not charted, and checklists are used for routine care
2. Works best with EHRs
d. Narrative Charting
i. Tells the story of pt’s experiences during their stay.
ii. Written in chronological order - admission - changes in condition, up to/incl d/c.
iii. Continual description of pt’s condition, complaints, and probs
iv. Assessment findings of all systems, activities, tx, and nursing care provided
v. Evaluations of effectiveness for each nursing intervention.
vi. More details than most charting styles + better timeline of pt’s condition
7. Electronic health records
a. What Is an Electronic Health Record?
i. An EHR is a record of an individual’s lifetime health information and is easily
updated and transferable.
ii. Used to document pts’ interactions, record tests, appointments, meds, signs
and symptoms, diseases, immunizations, and allergies.
iii. The nurse’s doc can > quality of care by reducing errors, emphasizing pt’s needs
and probs, and provide comm for all hc staff caring for a pt.
b. Protecting the Confidentiality of the EHR
i. Electronic access = beneficial. Info needed to care for ur pt is at ur fingertips.
ii. To access the EHR u need user ID and password assigned to you by your facility.
iii. P’s health record is password protected so that it can’t be viewed by
unauthorized staff.
iv. Keep ur user ID and pw in a safe place so they cannot be used by others
v. Computer systems can be hacked into illegally, which puts pt info at risk for
unauthorized access.
vi. Secure passwords must be changed at regular intervals.
vii. Safety: Never allow any other individual to see or use your password to access
patient records for any reason.
viii. A nurse only has access to records of pts for whom the nurse is caring.
c. Learning to Use the EHR
i. Further research needs to be conducted to identify what necessary updates and
enhancements are needed for facilities to provide higher-quality health care.
ii. Most facilities have computer stations at various locations in each pt hall, +
nurses’ station. Other facilities use bedside terminals
iii. When you have completed documenting on a pt’s EHR, remember to log out.
iv. Safety: Always log out as soon as you have completed your documentation to
prevent the chance of others documenting under your name.
d. Additional Uses for the EHR
i. EHRs help contribute to the development of evidence-based practice
ii. EHRs also provide a way for the hc community to collect and share info and
identify needs based on trends seen in them.
e. Continuing Education
i. All HCPs, including nurses, should participate in annual training to keep up w
advances in hc tech.
8. Long-term care documentation
a. Kardexes
i. Contains written data
ii. Used for quick reference about each resident’s care
iii. Lists all the care that should be provided for that specific resident.
iv. Places MD’s orders and nursing orders on a single page
v. Basic pt data and all MD’s and nursing orders are noted along w date ordered
b. Guidelines for Paper Documentation
i. Use black or blue ink. Avoid using pencil, erasable ink, or colored inks
ii. Write neatly and legibly.
iii. Sign each entry. Always sign each entry with your first initial, last name, and
credentials according to the facility’s policy.
iv. Include the date and time with each entry. Military time.
v. Follow chronological order.
vi. Make entries in a timely manner.
1. Safety: Document all assessment findings and the care provided as soon
as possible after the occurrence.
vii. Be succinct. Make entries brief, concise, and to the point.
viii. Use punctuation.
ix. Do not leave blank lines.
1. Safety: Avoid leaving a blank line, or even a blank portion of a line. Blank
lines serve as an invitation for another individual to write something in
the middle of your charting that could be attributed to you.
2. If you do not fill the line completely, draw a single straight line through
the middle of the space, extending from the last word to your signature.
Then sign your name and credentials
x. Use continued notes.
xi. Correct mistaken entries. If you make an incorrect entry, mark a single
horizontal line through the incorrect word or phrase. Write “mistaken entry”
and your initials just above. Then proceed with the correct entry.
1. Safety: Never use correction fluid or correction tape to totally blank out
the mistaken entry. Avoid using markers or making multiple ink marks in
an effort to blacken the incorrect entry so that it cannot be read
because this may raise suspicion regarding the entry. Also avoid trying
to “write over” incorrect letters. This only serves to make
documentation sloppy and difficult to read.
xii. Keep the medical record intact.
1. Safety: Never delete any part of the chart.
c. Long-Term Care Admission Documentation and Required Assessments
i. The Minimum Data Set for Resident Assessment and Care Screening
1. The Omnibus Budget Reconciliation Act (OBRA) mandates that an
extensive assessment form called the Minimum Data Set (MDS) for
Resident Assessment and Care Screening must be completed for each
resident within 4 days of admission to the facility and updated every 3
months.
2. Consists of many assessments that must be made. A partial list of
required assessments includes the following:
a. Demographics
b. Identification and background patterns
c. Customary routines of pt, incl cycle of daily events, eating
patterns, ADL patterns, and level of involvement w others
d. Communication and hearing patterns
e. Cognitive patterns
f. Vision patterns
g. Psychosocial well-being
h. Mood and behavior patterns
i. Physical functioning and structural-related problems
j. Continence of bowel and bladder
k. Health conditions
l. Disease DXs
m. Meds the patient is taking
ii. Weekly Assessment Data
1. Because the LTC facility is the home of the resident, some additional
data are collected and documented in the weekly assessments:
a. Use of all prostheses: glasses, dentures, hearing aids, limbs
b. Activity level: bedridden/amb, asst level
c. Elimination control and habits: continent/incontinent etc.
d. Nutrition versus malnutrition: type of diet, % routinely
consumed, type & frequency of supplemental nutrition, weight
records
e. Ability to communicate & method utilized to communicate
f. Visitors and support system
g. Social activities
h. Ability to perform ADLs: hygiene, dressing, nutrition, fluid intake
iii. Medication Administration Records
1. Med admin is charted each time meds are given
2. There is not a separate MAR for each day, admin of each drug is doc for
the entire month on 1 page.
9. Home health documentation
a. Most home health agencies use EHRs now.
b. Home health care documentation is governed by Centers for Medicare and Medicaid
Services (CMS).
c. Certain criteria must be met to admit a patient to home health care
d. Admission forms must be extensive to provide adequate data to verify that pt meets
certification requirements.
e. You must be an RN to perform this initial visit and assessment. Either RNs or LPNs may
make subsequent visits.
f. Each time you make a pt visit u will be expected to complete the skilled nursing note
form to document the visit.
10. Five documentation mistakes that carry increased risk of malpractice
a. Failure to Document Assessment Findings
i. Be competent in assessment and determine whether findings indicate a change
in the pt’s condition.
ii. Failure to identify and document even what may initially appear to be a minor
change in condition may put the pt in jeopardy.
iii. Some facilities have a policy stating that only the floor supervisors are to call
problems in to MDs, probs must be reported to supervisor when they’re id’d.
iv. Immediately go to ur supervisor and report the findings, assuming that the
supervisor will contact the MD and take care of the reported data.
v. You are responsible for documenting ur abnormal findings and the actions u
took to address any actual/potential probs related to those findings.
vi. Be diligent to document all assessment findings.
b. Failure to Document Medications Administered
i. Follow your facility’s policy for administering and documenting meds.
ii. Always record the drug name, dosage, and route of admin and the correct time
of admin asap.
iii. Failure to document admin of a med carries the potential for another mistake to
be made.
c. Failure to Document Pertinent Health History
i. I.e., Failure to document pt’s allergies to a med, food, or latex; a diagnosis; or a
previous MRSA infection.
d. Documenting on the Wrong Chart or MAR
i. Always check the electronic chart for pt’s full name, DOB, MD, other identifiers
as necessary before documenting in or following orders in the chart or MAR
e. Failure to Accurately Document Physician’s Orders
i. After the MD writes an order for any type of tx, test, procedure, the orders go
thru a process known as noting or transcribing the order.
ii. The process of doc that is required to ensure that the proper HCPs are notified
of the order.
iii. If the required doc isn’t completed, MD orders will not be delivered.
iv. Bc MD’s orders are the foundation of pt care, your accuracy in transcribing them
serves as the scaffolding for delivery of pt care.
v. Failure to accurately transcribe MD’s orders can have harmful consequences
and carries the potential to even be life threatening for pts.
11. Key points
a. Purposes of doc: continuity of care; a perm record of pt’s medical exp; a record of
accountability for quality assurance, accreditation, and reimbursement; and a legal
record for both the pt and HCPs.
b. HIPAA guarantees confidentiality of the pt’s medical record.
c. Forms used in doc: nursing report/printout, incident reports, care plans, pt’s med
record.
d. Guidelines for electronic doc include avoiding shortcuts, such as copy and paste; using
only approved abbreviations; and being accurate and objective.
e. There are two types of medical records: source-oriented and problem-oriented records,
and each is organized differently.
f. A variety of methods for recording pt info exist. With the use of EHRs, charting by
exception is often used. All nurses need to know how to record pt info using narrative
charting because it is used in a variety of settings.
g. EHR use is required by law for hospitals but not for LTC facilities. However, some
facilities are changing over to the use of EHRs.
h. When working in an EHR, it is important to never share your password.
i. In addition to the doc of pt care, an EHR provides a way to pool collected data and info,
provides evidence for evidence-based practice, and helps identify needs for staff
continuing education.
j. If you are using paper doc in LTC, many rules apply on how nurses’ notes are to be
written and corrected. Be sure you know and follow all these rules.
k. LTC doc frequency and emphasis are v diff from acute care doc. Home hc doc is also diff
from acute and LTC.
l. When using electronic doc, do not share your user ID and password with anyone.
12. KEY TERMS
a. Charting by exception: A type of charting in which only variances from “normal” in all
activities of daily living, vital signs, and assessment findings are charted as entries. This
method of charting is designed to drastically reduce time spent completing paperwork;
however, opinions vary about its efficacy and safety.
b. Confidentiality: The maintenance of privacy by not sharing with a third party privileged
or entrusted information.
c. Documentation: The act of charting or making a written notation of all the things that
are pertinent to each patient for whom a nurse provides care.
d. Electronic health record: A computerized database that typically includes present and
past medical and surgical information, laboratory information, radiographic information,
and drug information about a patient; most also contain billing and insurance
information as well.
e. Focus charting: A type of charting that is focused on the patient and patient concerns,
problems, and strengths. Unlike PIE charting, there is not a constructed list of specific
problems. It includes data, action, and response.
f. Kardex: A type of flip chart with a page for each patient on the unit or floor that
contains a summary of care required by the patient; it requires continual updating and
maintenance by nursing staff.
g. Narrative charting: A type of charting that details the patient’s experiences during a
hospital stay. It is written in chronological order and relates the patient’s health status
from admission and through all changes in condition, up to and including their discharge
status.
h. PIE charting: A type of charting style that is shorter and documents fewer data than the
SOAPIER charting style. It only addresses the patient’s problems; therefore the concept
of treating the patient holistically is lost. It stands for problem, interventions, and
evaluation.
i. SOAPIER charting: One of the lengthier documentation formats that typically is used in
progress notes and the nurse’s notes. It includes subjective data; objective data;
assessment data; a plan; an intervention; an evaluation; and, as needed, a revision.