King Saud University
College of Nursing
Medical Surgical Department
Module 10-123
Documenting
Recording
OR Charting
Prepared by:Mervat Mohamed
DOCUMENTING

A report: is oral, written, or
computer-based communication
intended to convey information to
others. For instance, nurses always
report on clients at the end of a
hospital work shift.
DOCUMENTING

A record: is written or computer-based. All
personnel involved in a patient’s health care
contribute to the medical record by charting,
recording, or documenting (process of writing information)
on the health agency’s forms.
Medical record, also called a chart or client record, is a
formal, legal document that provides information
about a person’s health problems, the care provided
by health practitioners, and the progress of the
patient. Although health care organizations use
different systems and forms for documentation, all
client records have similar information.
Documenting
Purposes of client records
A.
B.
C.
D.
Communication: patient’s record serves as the
vehicle by which different members of the health team
communicate and share information with each other.
Assessment: nurses and other health team members
gather assessment data from the patient’s record.
Planning patient care: the entire health team uses
data from the patient’s record to plan care for the
patient.
Education & research: nursing students, medical
students and other health team members often use
patient record as an educational tools. It provides a
comprehensive view of the patient’s health status. The
information contained in a record can be a valuable
source of data for research.
Documenting
Purposes of client records
E.
Legal documentation: the client’s record is a
legal document and is usually admissible in court
as evidence.
F.
Health care analysis: records can be used to
establish the costs of various services and to
identify those services that cost the agency
money and those that generate revenue.
G.
Auditing health agencies: patient’s record is
used to monitor the care received by the patient
and the competence of people giving that care.
Documenting
Types of Patient Records
1.
Source-Orient Records: records organized
according to the source of documented information.
This type of record contains separate forms on which
physicians, nurses, dietitians, physical therapists, and
so on. One of the criticisms of source-oriented records
is that it is difficult to demonstrate that there is a
unified, cooperative approach for resolving the
patient’s problems among caregivers.
2.
Problem-Orient Records: records organized
according to the patient’s health problems. Problemoriented records contain four major components: the
data base, the problem list, the plan of care, and
progress notes (Table 1). The information is arranged
to emphasize goal-directed care, and to facilitate
communication among health care professionals.
Documenting
Purposes of client records
Component Description
Database
Contains initial health information
Problem list
Consists of a numeric of the patient’s
health problems
Plan of care
Identifies methods for solving each
identified health problem
Progress notes
describes the patient’s response to what
has been done & revisions to the initial
plan
Table 1 common components of a problem-oriented record
Documenting
Methods of Charting
1.
Narrative charting: Narrative charting (style of
documentation generally used in source-oriented records)
involves writing information about the patient and
patient care in chronologic order. (Figure 1)
Nursing Notes
Date/time Nurses Remarks
13.30 pm
States “I am having chest pain. It’s like an
elephant is sitting on me” B. Zook, RN
13.40 pm
Skin is pale & moist. O2 started at 5L/min
Nitroglycerin tablet administered sublingual
Figure 1 Sample of narrative charting
Documenting
Types of Patient Records
2.
SOAP charting: SOAP charting (documentation style
more likely to be used in a problem-oriented record)
acquired its name from the four essential components
included in a progress note:
* S : subjective data
* O : objective data
* A : analysis of the data
* P : plan for care
SOAP charting helps to demonstrate interdisciplinary
cooperation, because everyone involved in the care of
a patient makes entries in the same location in the
chart. (Table 2)
Documenting
Types of Patient Records
Letter
Explanation
Nurses Remarks
Subjective
Information reported by the patient
S - “Don’t feel well”
Objective
Information reported by the nurse
O - Temperature 38C
Analysis
Problem identification
A – Fever
Plan
Proposed treatment
P – Increased fluid intake & Monitor
body temperature
Table 2 SOAP Charting format
Documenting
Types of Patient Records
Focus charting: Focus charting (modified form of SOAP
Charting) uses the word focus rather than problem,
because some believe that the word problem carries
negative connotations.
Focus charting used DAR model:
D = data category reflects the assessment phase of
the nursing process
A = action category reflects planning & implementation
phase of the nursing process.
R = response category reflect the evaluation of the
nursing process (Figure 2).
DAR notation tends to reflect the steps in the nursing
process.
Documenting
Types of Patient Records
6/6/2006
10.15 am
D (data) -
Bladder distended 2 fingers above pubis
Has not urinated since catheter was removed
A (action) –Assisted to toilet. Water turned on at faucet
R (response)- voided 525ml of clear urine L. Cass, SN
Figure 2 Example of DAR charting
Documenting
Types of Patient Records
4.
PIE charting:
PIE charting is method of recording the patient’s progress
under the headings of problem, intervention, and evaluation.
When the PIE method is used, assessments are documented
on separate form and the patient’s problems are given a
corresponding number (Figure 3).
Date/time
Nurses Remarks
6/6
8.30 am
P# 1 crackles heard on inspiration in the bases
of R and L lungs.
I# 1 splinted with pillow.
Instructed to breathe deeply, open mouth, and
cough at the end of expiration.
E# 1 Lungs clear with coughing. L Cass, HN
Figure 3 Sample of PIE charting
Documenting
Types of Patient Records
5.
Computerized Charting:
Computerized charting (documenting
patient information electronically) is most
useful for nurses when a terminal is
available at the point of care or beside
Documenting
General Guidelines for Recording
Because the client’s record is a legal document and may be
used to provide evidence in court, many factors are
considered in recording.
1.
Data & Time: Documenting the date and time of each
recording. This is essential not only for legal reasons but also
for client safety. Record the time in the conventional manner
(e.g. 9:00 am or 3:20 pm) or according to the 24-hours clock
(military clock).
2.
Timing: follow the agency’s policy about the frequency of
documenting, and adjust the frequency as a client’s condition
indicates; for example, a client whose blood pressure is
changing requires more frequent documentation than a client
whose blood pressure is constant.
3.
Legibility: all entries must be legible and easy to read
to prevent interpretation errors.
Documenting
General Guidelines for Recording
4.
Performance: all entries on the client’s record are made in
dark ink so that the record is permanent and changes can be
identified.
5.
Accepted Terminology: use only commonly accepted
abbreviations, symbols, and terms that are specified by the
agency.
6.
Correct Spelling: correct spelling is essential for accuracy
in recording. If unsure how to spell a word, look it up in a
dictionary.
7.
Signature: each recording on the nursing notes is signed by
the nurse making it. The signature includes the name and
title; for example, “Susan j. Green, RN” or “SJ Green, RN”
8.
Sequence: documenting events in the order in which they
occur; for example, record assessments, then the nursing
interventions, and then the client’s responses.
Documenting
General Guidelines for Recording
9.
Accuracy: the client’s name and identifying information
should be written on each page of the clinical record.
Accurate notations consist of facts or observations rather
than opinions or interpretations. It is more accurate, for
example, to write that the client “refused medication” (fact)
than to write that the client “was uncooperative” (opinion)
Good Luck