NURSING

DOCUMENTATION
 Documenting Your Findings
Documentation Methods
1. S o u r c e - o r i e n t e d
documentation
•is done by department, so
each healthcare group has a
section to document findings.
•This method easily identifies
each discipline, but it tends to
fragment the data, making it
difficult to follow the
sequencing of events.
 Documenting Your Findings
Documentation Methods
2. PROBLEM-ORIENTED MEDICAL
RECORDS (POMR)
•everyone involved in the care of the patient
charts on the same form.
•This allows for better communication of data
to resolve the patient’s problems
collaboratively.
 The advantage of POMR
a. it encourages collaboration
b. the problem list in the front of the chart
alerts caregivers to the client’s needs and
makes it easier to track the status of each
problem.
 Disadvantages
a. Caregivers differ in their ability to use the
required charting format,
b. It takes constant vigilance to maintain an
up-to-date problem list
c. It is somewhat inefficient because
assessments and interventions that apply
to more than one problem must be
repeated.
The POMR has four basic
components:
 Documenting Your Findings
Popular methods of problem-oriented
1.SOAPIE
2.PIE
3.DAR (FDAR)
4.Charting by exception (CBE)
5.Narrative Form
S—Subjective data
• Consist of information obtained from what
the client says.
• It describes the client’s perceptions of and
experience with the problem
• When possible, the nurse quotes the
client’s words; otherwise, they are
summarized.
 O—Objective data
• Consist of information that is measured or
observed by use of the senses (e.g., vital
signs, laboratory and x-ray results).
 A—Assessment
• is the interpretation or conclusions drawn
about the subjective and objective data.
• In all subsequent SOAP notes for that
problem, the “A” should describe the
client’s condition and level of progress
rather than merely restating the diagnosis
or problem.
P—The plan
• is the plan of care
designed to resolve
the stated problem.
• The initial plan is
written by the person
who enters the
problem into the
record.
• I—Interventions refer to the specific
interventions that have actually been
performed by the caregiver.
• E—Evaluation includes client responses
to nursing interventions and medical
treatments. This is primarily reassessment
data.
• R—Revision reflects care plan
modifications suggested by the evalu-
ation. Changes may be made in desired
outcomes, interventions, or target dates.
SAMPLE CASE
Mary Rutherford, age 43, is 1 day
postoperative after a cholecystectomy. Her
assessment data include the following:
• “It hurts to take a deep breath.”
• Pain rated 8/10
• Guarding abdomen
• Vital signs: BP 144/90; pulse 108;
respirations 24 and shallow; temperature
100.8︎F
• Pulse oximeter 92 percent on room air
• Decreased breath sounds at bases owing
to poor ventilatory effort, also few crackles
noted at bases
• Receiving patient-controlled analgesia
(PCA) morphine
• Dressings dry and intact
 Documenting Your Findings
SOAPIE Method
■ Subjective data
“It hurts to take a deep breath”:
•Pain increases with activity and breathing, PCA
helps; pain is sharp; pain is located in right
upper quadrant (RUQ) and epigastric region;
pain is rated 8/10; pain only when moving.
 Documenting Your Findings
■ Objective data
First-day postop cholecystectomy;
•vital signs: BP,144/90; pulse, 108; respirations, 24
and shallow;
•temperature, 100.8F; pulse oximeter, 92 percent on
room air;
•patient guarding abdomen;
• decreased breath sounds at bases because of poor
ventilatory effort, also few crackles noted at bases;
•receiving PCA morphine.
 Documenting Your Findings
Assessment/clinical judgment
• Ineffective breathing pattern related to
incisional pain.

Plan
• Patient will establish effective breathing
pattern; patient will experience no signs of
respiratory complications.
 Documenting Your Findings
Interventions
• Encourage coughing and deep breathing;
teach patient to splint incision; control pain
with PCA;
• Encourage ambulation;
• provide instruction on use of incentive
spirometer;
• maintain adequate hydration.
 Documenting Your Findings
Evaluation
• Patient coughing and deep breathing,
splinting incision;
• using incentive spirometer; ambulating;
pain 5/10, using PCA morphine as
needed;
• lungs clear; vital signs:BP 130/86,
temperature 99F, pulse 80, respirations
20, pulse oximeter 96% on room air.
DAR METHOD

Focus Charting
 Focus charting
• is intended to make the client and client
concerns and strengths the focus of care.
 Focus Charting Parts
Three columns are usually used in Focus
Charting for documentation:
• Date and Hour
• Focus
• Progress Notes
• The progress notes are organized into (D)
data, (A) action, and (R) response,
referred to as DAR (third column).
 Here is an example of a format of Focus
Charting or F-DAR
Date/Hour Focus Progress Notes

1/24/2022 Focus of care, Data

8am this may be: a Action
n u r s i n g Response
diagnosis a sign
or a symptom
an acute change
in the condition
 Focus charting
• The focus
– may be a condition
– a nursing diagnosis,
– a behavior,
– a sign or symptom,
– an acute change in the client’s condition,
– or a client strength.
 The data
• category reflects the assessment phase of
the nursing process and consists of
observations of client status and
behaviors, including data from flow sheets
(e.g., vital signs, pupil reactivity).
• The nurse records both subjective and
objective data in this section.
 The action
• category reflects planning and
implementation and includes immediate
and future nursing actions.
• It may also include any changes to the
plan of care.
 Response category

• The reflects the evaluation phase of the

nursing process and describes the
client’s response to any nursing and
medical care.
• The three components do not need to be
recorded in order and each note does not
need to have all three categories.
Date/Hour Focus Progress Notes
1/24/2022 Pain D:
8:00am •Reports of sharp pain on the abdominal
incision area with a pain scale of 8 out of 10
•Facial grimacing
•Guarding behavior
•Restless and irritable

A:
•Administered Celecoxib 200mg IV
•Encouraged deep breathing exercises and
relaxation techniques
Kept patient comfortable and safe

R:
•Patient reports pain was relieved
DAR METHOD
 DAR Method
DATA
•“It hurts to take a deep breath”;
• pain increases with activity and
breathing, PCA helps; pain is sharp;
• pain is located in RUQ and epigastric
region; pain is rated 8/10;
•pain only when moving;first-day postop
cholecystectomy;
 DAR Method
DATA
• Vital signs: BP 144/90; pulse 108; respirations
24 and shallow;
• Temperature 100.8f;
• Pulse oximeter 92 percent on room air;
• Patient guarding abdomen;
• Decreased breath sounds at bases because
of poor ventilatory effort, also few crackles
noted at bases;
• Receiving PCA morphine.
 DAR Method
ACTION
• Encourage coughing and deep breathing;
• Teach patient to splint incision;
• Control pain with PCA;
• Encourage ambulation;
• Provide instruction on use of incentive
spirometer;
• Maintain adequate hydration.
 DAR Method
RESPONSE
• Patient coughing and deep breathing,
splinting incision;
• Using incentive spirometer; ambulating;
• Pain 5/10, using PCA morphine as needed;
• Lungs clear;
• Vital signs:bp 130/86, temperature 99F,
pulse 80, respirations 20, pulse oximeter 96
percent on room air.
PIE Method
 PIE NOTES
• P: PROBLEM ( Find the problem from the list at
the beginning of the multidisciplinary note
section of the chart) EX. Alteration of comfort
• I: INTERVENTION Is all the you see, hear, feel,
read, do and that someone else has done for the
client
– This section usually starts with an assessment that
you do with regard to collecting data about the
problem
• E: EVALUATION STATUS OF THE PROBLEM
WHEN YOU WRITE THE NOTE
 PIE Method
PROBLEM
• Ineffective breathing pattern related to incisional
pain.
INTERVENTIONS
• Encourage coughing and deep breathing;
• Teach patient to splint incision;
• Control pain with PCA;
• Encourage ambulation;
• Provide instruction on use of incentive
• Spirometer; maintain adequate hydration.
 PIE Method
EVALUATION
• Patient coughing and deep breathing,
splinting incision;
• Using incentive spirometer;
• Ambulating;
• Pain 5/10, using PCA morphine as needed;
• Lungs clear;
• Vital signs: BP 130/86, temperature 99F,
pulse 80, respirations 20, pulse oximeter 96
percent on room air.
Narrative Method
NARRATIVE METHOD
• Chronological
• Baseline charted qshift
• Lengthy, time-consuming
• Separate pages for each
• Source-oriented
 Narrative Method
• Whatever format or method is used,
you need to document accurately
and concisely.
• Documentation is a part of your
patient’s permanent record, and the
information is confidential.
 Narrative Method
• 10/3/05 8 A.M. Patient stated,“It hurts to take a deep
breath.” Rates pain 8/10, guarding, vital signs BP
144/90, temperature 100.8, pulse 108, respirations
24 and shallow, pulse oximetry 92 percent on room
air.
• Decreased breath sounds at bases owing to poor
inspiratory effort. Dressings dry and intact. Reviewed
use of PCA morphine and incentive spirometer with
patient.
• Patient instructed to cough and deep breathe with
splinting. Pat Win,RN
 Narrative Method
• 9 A.M. Patient coughing and deep
breathing,using incentive spirometer.
ambulating with assistance, using PCA
morphine prn pain, 5/10, lungs clear. Vital
signs: BP 130/86, temperature 99°F, pulse
80, respirations 20, pulse oximetry 96
percent on room air. Gary Dy, RN