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Charting and Documentation Notes

Charting and documentation is important for keeping medical and legal records of a patient's care. There are several types of charting including narrative notes, SOAPIE notes, and FDAR/DAR notes. Narrative notes use a simple chronological format while SOAPIE notes are organized into subjective, objective, assessment, plan, interventions, and evaluation sections. FDAR/DAR notes focus on a key concern and include data, actions, and the patient's response. Other documentation includes parenteral fluid sheets to monitor intravenous fluids, physician's order sheets to guide medical services, and TPR sheets to track vital signs like temperature, pulse, and respiration over time.

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Cyriel Dico
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199 views

Charting and Documentation Notes

Charting and documentation is important for keeping medical and legal records of a patient's care. There are several types of charting including narrative notes, SOAPIE notes, and FDAR/DAR notes. Narrative notes use a simple chronological format while SOAPIE notes are organized into subjective, objective, assessment, plan, interventions, and evaluation sections. FDAR/DAR notes focus on a key concern and include data, actions, and the patient's response. Other documentation includes parenteral fluid sheets to monitor intravenous fluids, physician's order sheets to guide medical services, and TPR sheets to track vital signs like temperature, pulse, and respiration over time.

Uploaded by

Cyriel Dico
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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CHARTING AND DOCUMENTATION

Chart

- It is a document where most of the client’s information are kept or being


written.
- The purpose of a medical chart:
- - is to serve as both a medical and legal record of an individual's clinical
status, care, history, and caregiver involvement.
- - the specific information contained in the chart is intended to provide a
record of a person's clinical condition by detailing diagnoses, treatments
and responses to treatment, as well as any other factors that may affect
the person's health or clinical state.

Types of Charting

1. Narrative form
- Uses a simple chronological format to document patient care over
the course of the shift.
- Nursing notes usually consists of a series of entries connected to the
times that describes the patient’s status, the nursing interventions
and treatments, and the patient’s response to the interventions
- Example:

Date Time Confused. Calling for the son. Does not


6-7-11 8:00am remember she is in the hospital. Course
breaths sounds heard upon auscultation.
Cough productive of thick yellow
sputum. Encouraged to drink fluids to
loosen secretions. No complaints of pain
at the time. Medications given
namely: Coamoxiclav 650mg 1 tab bid
Call bell at bedside.
9:30am Prepared for physical therapy.
Unsteady on feet noted.
2. SOAPIE
- is a mnemonic for a type of progress note that is organized by six
categories: Subjective, Objective, Assessment, Plan, Interventions,
and Evaluation. SOAPIE progress notes are written by nurses, as
well as other members of the health care team.
- Subjective: This section includes what the patient said, such as, “I
have a headache.” It can also contain information related to
pertinent medical history and why the patient is in need of care.
- Objective: This section contains the observable and measurable
data collected during a patient assessment, such as the vital signs,
physical examination findings, and lab/diagnostic test results.
- Assessment: This section contains the interpretation of what was
noted in the Subjective and Objective sections, such as a nursing
diagnosis in a nursing progress note or the medical diagnosis in a
progress note written by a health care provider.
- Plan: This section outlines the plan of care based on the
Assessment section, including goals and planned interventions.
- Interventions: This section describes the actions implemented.
- Evaluation: This section describes the patient response to
interventions and if the planned outcomes were met.
- Example:
S-“Hindi ako nagbaBT kase wala pang pera”- as verbalized by the patient
O-Received on bed on supine position conscious and coherent, with
intactand unsoaked incision dressing, (-) breast engorgement, urine (1), (-
)BM,unsoaked vaginal/perineal pads with moderate amount of lochia
serosa, (-)Homan’s sign, ambulatory, pale buccal mucosa and conjunctiva,
hgb count (77), hct (0.33),with initial vital signs taken as follows: BP-
120/80 mmHg, PR-83 bpm, RR-26 bpm, Temp.-36.4
A-Altered Tissue Perfusion r/t decrease hgb(77), hct(0.33) countS
P-After 2 hrs of nursing intervention, the patient will verbalize
understanding of the condition, treatment/therapy regimen, and will
demonstrate behavioral changes to improve circulation.
I- Assessed for factors that could precipitate to anemia such
as bleeding onincision site, excessive lochia and diet.
-Encouraged to increase intake of food rich in iron such as animal liver
&green & leafy vegetables when in DAT status
-Instructed to watch for sign of bleeding on incision site (soaked
dressing) and increase in lochia and diet
-Instructed compliance to oral iron supplement intake
E-Patient verbalized understanding of condition and therapeutic regimen
and demonstrated behavioral changes to improve circulation

3. FDAR/DAR
- Is a method in organizing health information in the individual’s
record. It is systematic approach to documentation, to describe
individual’s health status and nursing action with a given focus.
- F stands for- Focus – a key word for nursing diagnosis or
collaborative problem in the plan of care.
ex. Skin integrity, coping, activity intolerance, self-care
deficit
- It could be a current individual concern or behavior
ex. Nausea, chest pain, pre-op teaching, discharge teaching
- Data - subjective/ objective cues
- Action - nursing interventions performed
- Response - descriptions an individual’s response to medical or
nursing care
- Example:
Focus – Comfort(Relief of Pain)
D - complaining of continuous sharp pain in mid-abdominal area. Crying” I
need something for pain now” states pain is 9 on the scale of 10.
A - medicated with Demerol 75 mg IM in left buttocks.
Repositioned on right side with pillow to abdomen to help splint
wound
R - patient stated pain was “much better”, 30 minutes later and rated it 3
on the a scale of 10.

Parenteral Fluid Sheet

- It serves as your guide to monitor the number of fluids that was


being given to the patient.

Doctor’s / Physician’s Order Sheet

- It is the nurse’s guide in providing a good medical service.


- Must be legible, handwriting
- Date and time is very important in documenting and
transcribing/carry-out physician’s order.

TPR Sheet

- TPR stands for Temperature and Pulse rate


- Always use Blue for Temperature and Red for Pulse rate
- For Respiratory and BP you may use both color depending on the
Shift
- AM/PM shift: Blue
- Night Shift: Red
- Note: odd numbers: space
Even numbers: line
- Always encircle 37(blue) and 80(red) - depending on the hospital
policy.

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