Nursing Process and

Documentation
• The nursing process is a systematic, rational method of
planning and providing individualized nursing care.
• The client may be an individual, a family, a community,
or a group.
• Its purposes are :
to identify a client’s health status and actual or
potential health care problems or needs
to establish plans to meet the identified needs,
to deliver specific nursing interventions to meet those
needs.
• Hall originated the term nursing process in 1955, and
Johnson
(1959), Orlando (1961), and Wiedenbach (1963) were
among the first to use it to refer to a series of phases
describing the practice of nursing.
• Since then, various nurses have described the process
of nursing and organized the phases in different ways.
• The use of the nursing process in clinical practice
gained additional legitimacy in 1973 when the phases
were included in the American Nurses Association
(ANA) Standards of Nursing Practice.
 Phases of the Nursing Process
• six phases of the nursing process: (ANA, 2010).
1. Assessment
2. Diagnosis
3. outcomes identification
4. Planning
5. Implementation
6. evaluation
ADVANTAGES OF NURSING PROCESS.
Provides individualized care
Client is an active participant
Promotes continuity of care
Provides more effective communication among nurses and healthcare
professionals
Develops a clear and efficient plan of care
Provides personal satisfaction as you see client achieve goals
Professional growth as you evaluate effectiveness of your
interventions
 Characteristics of the Nursing Process

• The nursing process has distinctive characteristics that enable the nurse to
respond to the changing health status of the client.
• These characteristics include
1. its cyclic and dynamic nature-Data from each phase provide input into the next
phase.
2. client centeredness
3. focus on problem solving - It can be viewed as parallel to but separate from the
process used by physicians (the medical model).
4. decision making
5. Interpersonal and collaborative style
6. universal applicability
7. use of critical thinking and clinical reasoning
The Nursing Care Process
• Assessment
• Nursing diagnosis
• Plan
• Implementation
• Evaluation
• The nursing care plan.
 The nursing process in action
1. ASSESSING 2. DIAGNOSING
• Collect data • Analyze data
• Organize data • Identify health problems, risks, and strengths
• Validate data • Formulate diagnostic statements
• Document data

3 . PLANNING 4. PLANNING
• Prioritize problems/diagnoses • Prioritize problems/diagnoses
• Formulate goals/desired outcomes • Formulate goals/desired outcomes
• Select nursing interventions • Select nursing interventions
• Write nursing interventions • Write nursing interventions

5. IMPLEMENTING 6. EVALUATING
• Reassess the client • Collect data related to outcomes
• Determine the nurse’s need for assistance • Compare data with outcomes
• Implement the nursing interventions • Relate nursing actions to client goals/outcomes
• Supervise delegated care • Draw conclusions about problem status
• Document nursing activities • Continue, modify, or terminate the client’s care plan
• ASSESSING
• Assessing is the systematic and continuous collection,
organization, validation, and documentation of data
(information)
• In effect, assessing is a continuous process carried out
during all phases of the nursing process. For example,
in the evaluation phase, the client is reassessed to
determine the outcomes of the nursing strategies and
to evaluate goal achievement.
• All phases of the nursing process depend on the
accurate and complete collection of data.
• Assessments vary according to their purpose, timing, time
available, and client status.
• Nursing assessments focus on a client’s responses to a health
problem.
• A nursing assessment should include the client’s perceived
needs, health problems, related experience, health practices,
values, and lifestyles.
• To be most useful, the data collected should be relevant to a
particular health problem.
• Therefore, nurses should think critically about what to assess.
• The nursing assessment also involves
the elicitation of clients’ own perspectives on
their condition;
identifying barriers to communication
 recognizing the impact of the nurse’s own
attitudes values, and beliefs on the assessment
process
family dynamics in assessment
increased emphasis on protection of the privacy
of data
 Types of Assessment

Initial Performed within specified time after

assessment admission to a health care agency

Problem- Ongoing process integrated with

focused nursing care
assessment
 Types of Assessment
Emergency During any physiological or
assessment psychological crisis of the client

Time-lapsed Several months after initial assessment

reassessment
ASSESSMENT PHASE ACTIVITIES

The assessment
process involves
four related
activities:
collecting data,
organizing data,
validating data,
and documenting
data.
1.COLLECTING DATA
• Data collection is the process of gathering
information about a client’s health status.
• It includes the health history, physical
examination, results of laboratory and
diagnostic tests, and material contributed by
other health personnel
 Types of Data
• Subjective data, also referred to as symptoms or covert data, are
apparent only to the person affected and can be described or
verified only by that person.
• Itching, pain, and feelings of worry are examples of subjective data.
• Subjective data include the client’s sensations, feelings, values,
beliefs, attitudes, and perception of personal health status and life
situation.
• Objective data, also referred to as signs or overt data, are
detectable by an observer or can be measured or tested against an
accepted standard.
• Sources of Data
• Sources of data are primary or secondary.
• The client is the primary source of data.
• Family members or other support persons, other health
professionals, records and reports, laboratory and
diagnostic analyses, and relevant literature are secondary
or indirect sources.
• In fact, all sources other than the client are considered
secondary sources.
• All data from secondary sources should be validated if
possible.
Data Collection Methods
• The methods used to collect data are observation, interview
and examination.
 Observation: It is gathering data by using the senses. Vision, Smell and
Hearing are used.
 Interview: An interview is a planned communication or a conversation
with a purpose. There are two approaches to interviewing: directive and
nondirective.
 The directive interview is highly structured and directly ask the questions.
And the nurse controls the interview.
 A nondirective interview, or rapport building interview and the nurse
allows the client to control the interview.
 • Stages of an Interview
• An interview has three major stages: The opening or
introduction, the body or development, and the closing.
Examination: The physical examination is a systematic data
collection method to detect health problems.
To conduct the examination, the nurse uses techniques of inspection,
palpation, percussion and auscultation.
2. ORGANIZATION OF DATA
• The nurse uses a format that organizes the assessment data
systematically. This is often referred to as nursing health history
or nursing assessment form.
3. VALIDATION OF DATA
• The information gathered during the assessment is “double-
checked” or verified to confirm that it is accurate and complete.
4. DOCUMENTATION OF DATA
• To complete the assessment phase, the nurse records client data.
Accurate documentation is essential and should include all data
collected about the client’s health status.
 Diagnosing
• Diagnosing is the second phase of the nursing
process.
• In this phase, nurses use critical thinking skills to
interpret assessment data and identify client
strengths and problems.
• Diagnosing is a pivotal step in the nursing process.
• diagnosis is a statement or conclusion regarding the
nature of a phenomenon.
• READING ASSIGNMENT
• The identification and development of nursing diagnoses
began formally in 1973, when two faculty members of Saint
Louis University, Kristine Gebbie and Mary Ann Lavin,
perceived a need to identify nurses’ roles in an ambulatory
care setting.
• The first national conference to identify nursing diagnoses
was sponsored by the Saint Louis University School of Nursing
and Allied Health Professions in 1973.
• Subsequent national conferences occurred in 1975, in 1980,
and every 2 years thereafter.
Reading assignment
• International recognition came with the First Canadian
Conference in Toronto in 1977 and the International Nursing
Conference in May 1987 in Calgary, Alberta, Canada. In 1982,
the conference group accepted the name North American
Nursing Diagnosis Association (NANDA), recognizing the
participation and contributions of nurses in the United States
and Canada.
• In 2002, the organization changed its name to NANDA
International to further reflect the worldwide interest in
nursing diagnosis
• The purpose of NANDA International is to define, refine, and
promote a taxonomy of nursing diagnostic terminology of
general use to professional nurses.
• A taxonomy is a classification system or set of categories
arranged based on a single principle or set of principles.
• The members of NANDA include staff nurses, clinical
specialists, faculty, directors of nursing, deans, theorists, and
researchers.
• The group has currently approved more than 200 nursing
diagnosis labels for clinical use and testing.
 Types of nursing diagnosis
• The kinds of nursing diagnoses according to status are
actual, health promotion, risk, and syndrome.
• 1. An actual diagnosis is a client problem that is
present at the time of the nursing assessment.
• Examples are Ineffective Breathing Pattern and
Anxiety.
• An actual nursing diagnosis is based on the presence
of associated signs and symptoms.
2. A health promotion diagnosis relates to clients’
preparedness to implement behaviors to improve their health
condition.
These diagnosis labels begin with the phrase Readiness for
Enhanced, as in Readiness for Enhanced Nutrition.
3. A risk nursing diagnosis is a clinical judgment that a problem
does not exist, but the presence of risk factors indicates that a
problem is likely to develop unless nurses intervene.
4. A syndrome diagnosis is assigned by a nurse’s clinical
judgment to describe a cluster of nursing diagnoses that have
similar interventions
Components of a NANDA Nursing Diagnosis
• A nursing diagnosis has three components:
• (1) the problem and its definition
• (2) the etiology
• (3) the defining characteristics.
• Each component serves a specific purpose
 1. Analyzing Data
• In the diagnostic process, analyzing involves the following
steps:
• 1. Compare data against standards (identify significant
cues).
• 2. Cluster the cues (generate tentative hypotheses).
• 3. Identify gaps and inconsistencies.
• For experienced nurses, these activities occur continuously
rather than sequentially
2. Formulating Diagnostic Statements
• Most nursing diagnoses are written as two-part
or three-part statements, but there are
variations of these.
 BASIC TWO-PART STATEMENTS
• The basic two-part statement includes the following:
• 1. Problem (P): statement of the client’s response (NANDA label)
• 2. Etiology (E): factors contributing to or probable causes of the
responses.
• The two parts are joined by the words related to rather than due to.
• The phrase due to implies that one part causes or is responsible for the
other part.
 BASIC THREE-PART STATEMENTS
The basic three-part nursing diagnosis statement is called
the PES format and includes the following:
1. Problem (P): statement of the client’s response
(NANDA label)
2. Etiology (E): factors contributing to or probable causes
of the response
3. Signs and symptoms (S): defining characteristics
manifested by the client.
 ONE-PART STATEMENTS
• Some diagnostic statements, such as health promotion
diagnoses and
• syndrome nursing diagnoses, consist of a NANDA label only.
• As the diagnostic labels are refined, they tend to become
more specific, so that nursing interventions can be derived
from the label itself.
• Therefore, an etiology may not be needed.
VARIATIONS OF BASIC FORMATS

Variations of the basic one-, two-, and three-part statements

include
the following:
1. Writing unknown etiology when the defining characteristics
are
present but the nurse does not know the cause or
contributing
factors. One example is Noncompliance (Medication Regimen)
related to unknown etiology.
2. Using the phrase complex factors when
there are too many etiologic factors or when
they are too complex to state in a brief phrase.
The actual causes of chronic low self-esteem,
for instance, may be long term and complex,
as in the following nursing diagnosis: Chronic
Low Self-Esteem related to complex factors.
3. Using the word possible to describe either the
problem or the etiology. When the nurse believes
more data are needed about the client’s problem or
the etiology, the word possible is inserted.
Examples are Possible Low Self-Esteem related to loss
of job and rejection by family; Altered Thought
Processes possibly related to unfamiliar surroundings.
• 4. Using secondary to to divide the etiology into
two parts, thereby making the statement more
descriptive and useful.
The part following secondary to is often a
pathophysiologic or disease process or a medical
diagnosis, as in Risk for Impaired Skin Integrity
related to decreased peripheral circulation
secondary to diabetes.
5. Adding a second part to the general response or
NANDA label to make it more precise. For
example, the diagnosis Impaired Skin Integrity
does not indicate the location of the problem.
To make this label more specific, the nurse can
add a descriptor as follows: Impaired Skin Integrity
(Left Lateral Ankle) related to decreased
peripheral circulation
 The following suggestions help to minimize
diagnostic error:
• Verify. Hypothesize possible explanations of the data, but realize that
all diagnoses are only tentative until they are verified.
• Build a good knowledge base and acquire clinical experience.
• Have a working knowledge of what is normal.
• Consult resources.
• Base diagnoses on patterns—that is, on behavior over time—rather
than on an isolated incident.
• Improve critical thinking skills.
 Differentiating Between Nursing Diagnosis
from Medical Diagnosis
NURSING DIAGNOSIS MEDICAL DIAGNOSIS
A nursing diagnosis is a statement of A medical diagnosis is made by a physician.
nursing judgment that made by nurse, by
their education, experience, and
expertise, are licensed to treat...
Nursing diagnoses describe the human Medical diagnoses refer to disease
response to an illness or a health problem processes.

Nursing diagnoses may change as the A client’s medical diagnosis remains the
client’s responses change same for as long as the disease is present.
 Planning
• Planning is a deliberative, systematic phase of the nursing process
that involves decision making and problem solving.
• In planning, the nurse refers to the client’s assessment data and
diagnostic statements for direction in formulating client goals and
designing the nursing interventions required to prevent, reduce, or
eliminate the client’s health problems
• A nursing intervention is “any treatment, based upon clinical
judgment and knowledge, that a nurse performs to enhance
patient/client outcomes” (Bulechek, Butcher, Dochterman, & Wagner,
2013, p. xv).
• The end product of the planning phase is a client care plan.
 TYPES OF PLANNING
• Planning begins with the first client contact and
continues until the nurse–client relationship ends,
usually when the client is discharged from the health
care agency.
 Initial Planning
• The nurse who performs the admission assessment usually develops
the initial comprehensive plan of care.
This nurse has the benefit of seeing the client’s body language and can
also gather some intuitive kinds of information that are not available
solely from the written database.
• Planning should be initiated as soon as possible after the initial
assessment.
• Ongoing Planning
• All nurses who work with the client do ongoing planning.
• As nurses obtain new information and evaluate the client’s responses to
care, they can individualize the initial care plan further.
• Ongoing planning also occurs at the beginning of a shift as the nurse plans
the care to be given that day.
• Using ongoing assessment data, the nurse carries out daily planning for
the following purposes:
• 1. To determine whether the client’s health status has changed
• 2. To set priorities for the client’s care during the shift
• 3. To decide which problems to focus on during the shift
• 4. To coordinate the nurse’s activities so that more than one problem can be
addressed at each client contact.
 Discharge Planning

• Discharge planning, the process of anticipating

and planning for needs after discharge, is a
crucial part of a comprehensive health care plan
and should be addressed in each client’s care
plan.
1. Setting priorities
The nurse begins planning by deciding which nursing diagnosis
requires attention first, second, third and so on.
Nurses frequently use Maslow’s hierarchy of needs when setting
priorities.
 After choosing the appropriate nursing interventions, the nurse writes
them on the care plan.
 Nursing care plan is a written or computerized information about the
client’s care.
 2. Establishing client goals/desired
outcomes
After establishing priorities, the nurse set goals for each nursing
diagnosis. Goals may be short term or long term. Goal and outcome
statements are client focused.
 Worded positively
 Measurable, specific observable, time-limited, and realistic
 Goal = broad statement
 Goals are patient-centered and SMART (Specific Measurable Attainable Relevant
Time Bound) for example; Patient will walk 50 ft. Patient will eat 75% of meal,
Patient will maintain HR<100 Patient will state pain level is acceptable 6 (0-10)
 Expected outcome = objective criterion for measurement of goal
 Goal: Client will achieve therapeutic management of disease process.
 Outcome Statement: AEB B/P readings of 110-120 / 70-80 and client statement
of understanding importance of dietary sodium restrictions by day of discharge.
3. Nursing interventions
• A nursing intervention is any treatment, that a nurse performs
to improve patient’s health.
• Types of Nursing Interventions
Independent interventions are those activities that nurses are
licensed to initiate on the basis of their knowledge and skills.
Dependent interventions are activities carried out under the orders
or supervision of a licensed physician.
Collaborative interventions, are actions the nurse carries out in
collaboration with other health team members
Writing Individualized Nursing Interventions
 The nurse uses clinical judgment and professional knowledge to
select appropriate interventions that will aid the client in reaching
their goal.
 Interventions should be examined for feasibility and acceptability to
the client
 After choosing the appropriate nursing interventions, the nurse writes
them on the care plan.
 Nursing care plan is a written or computerized information about the
client’s care.
 IMPLEMENTATION
Implementation consists of doing and documenting
the activities. The process of implementation includes;
Implementing the nursing interventions and
Documenting nursing activities.
The activities include: monitoring, teaching, further
assessing, reviewing NCP, incorporating physicians’
orders and monitoring cost effectiveness of
interventions.
 Process of Implementing
The process of implementing normally includes the
following:
• Reassessing the client
• Determining the nurse’s need for assistance
• Implementing the nursing interventions
• Supervising the delegated care
• Documenting nursing activities
 EVALUATION

Evaluation is a planned, ongoing, purposeful activity

in which the nurse determines: the client’s progress
toward achievement of goals/outcomes and the
effectiveness of the nursing care plan.
The evaluation includes; Comparing the data with
desired outcomes, Continuing, modifying, or
terminating the nursing care plan.
 Recording (Documentation) and Reporting
 A report is oral, written, or computer-based communication intended to convey
information to others.
 A record/ chart/ or client record, is a formal, legal document that provides
evidence of a client’s care and can be written or computer based.
 Recording, charting, or documenting: The process of making an entry on a
client record.
 Documentation is anything written or printed on which you rely as record or
proof of patient actions and activities.
 Each health care organization has policies about recording and reporting client
data, and each nurse is accountable for practicing according to these standards.
 PURPOSES FOR KEEPING CLIENT
RECORDS.
The patient record is a valuable Research,
source of data for all members of  Education,
the health care team.
Reimbursement,
Client records are kept for a
number of purposes including: Legal documentation,

Communication Health care analysis.

Planning client care,

Auditing health agencies,
1. COMMUNICATION
The record serves as the vehicle by which different health
professionals who interact with a client communicate with each other.
Communication prevents fragmentation, repetition, and delays in
client care.
Lack of communication creates situations where medical errors can
occur. These errors have the potential to cause severe injury or
unexpected patient death.
Effective communication takes place along two approaches:
Recording and reporting.
 • 2. PLANNING CLIENT CARE
Each health professional uses data from the client’s
record to plan care for that client.
 Nurses use baseline and ongoing data to evaluate the
effectiveness of using care plan.
The physicians plan treatment after seeing the
laboratory reports of patient.
 •3. AUDITING HEALTH
AGENCIES
An audit is a review of client records for
quality assurance purposes. Accrediting
agencies such as the Joint Commission
may review client records to determine if
a particular health agency is meeting its
stated standards or not.
 • 4. RESEARCH
The information contained in a record can be a
valuable source of data for research.
 The treatment plans for a number of clients
with the same health problems can yield
information helpful in treating other clients.
 • 5. EDUCATION
Students in health disciplines often use
client records as educational tools.
A record can frequently provide a
comprehensive view of the client, the
illness and effective treatment strategies.
 •6. REIMBURSEMENT
Documentation also helps a facility receive
reimbursement from the government.
 For a patient to obtain payment through
insurance agencies the client’s clinical
record must contain the correct diagnosis
and reveal the appropriate care the patient
received.
 • 7. LEGAL DOCUMENTATION
The client’s record is a legal document and is usually
admissible in court as evidence.

• 8. HEALTH CARE ANALYSIS

Information from records may assist health care planners to
identify agency needs, such as over utilized and
underutilized hospital services.
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.
 KEY CONTENTS OF ALL RECORDS
Patient identification and Therapeutic orders
demographic data Medical and health discipline
Informed consent for treatment and progress notes
procedures Physical assessment findings
Admission data Diagnostic study results
Nursing diagnoses or problems and Patient education
nursing care plan Summary of operative procedures
Record of nursing care treatment Discharge plan and summary
and evaluation
Medical history
Medical diagnoses
TYPES OF NURSING RECORDS
Admission nursing assessment
 Nursing care plan
 Kardexes -is a desktop file system that gives a brief overview of each patient and
is updated every shift.
 Nursing Progress notes
 Pertinent information about patient
 Medication with date of order & time of administration
 Daily treatment and procedures
 Flow chart
 Graphic record (TPRBP)
 Fluid balance record
Admission nursing assessment
Nursing care plan
Kardexes -is a desktop file system that gives a brief
overview of each patient and is updated every shift.
Progress notes
Nursing progress notes
Pertinent information about patient
Medication with date of order & time of
administration
Daily treatment and procedures
Graphic record (TPRBP)
Fluid balance record
 COMMON REPORTS GIVEN BY
NURSES
Change-of- shift reports
Telephone reports
Hand-off reports
Incident reports.
Principles of recording

• The principles of recording include;

• Factual, Timing, legibility, Permanence,
accepted terminology, Correct signature,
Spelling, accuracy, Sequence,
Appropriate, Complete, Concise, and
Legal prudence.
 • 1. Factual
A factual record contains descriptive, objective information. for
example, Information obtained by the nurse through history taking
and physical examination.
Avoid vague terms such as appears, seems, or apparently because
these words suggest that you are stating an opinion.
Objective documentation example is “the patient’s pulse rate is
elevated at 110 beats/min, respiratory rate is slightly labored at 22
breaths/min, and the patient reports increased restlessness.” The only
subjective data included in the record are what the patient says.
 When recording subjective data, document the patient’s exact words
within quotation marks whenever possible.
 • 2. Date and time
 Document 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 3:15 PM) or according to the 24-
hour clock.
•
• 3. Timing
 Follow the agency’s policy about the frequency of documenting, and
adjust the frequency as a client’s condition indicates.
 As a rule, documenting should be done as soon as possible after an
assessment or intervention. No recording should be done before providing
nursing care
 • 4. legibility
 All entries must be legible and easy to read to prevent interpretation errors.
•
• 5. Permanence
 All entries on the client’s record are made in dark ink so that the record is
permanent and changes can be identified. Follow the agency’s policies about
the type of pen and ink used for recording.
•
• 6. Accepted terminology
 Use only the standard and recognized abbreviations.
 Ambiguity occurs when an abbreviation can stand for more than one term
leading to misinterpretation. For example, CP stand for chest pain, cerebral
palsy, cleft palate, creatine phosphate, and chickenpox
 • 7. Correct signature
 Each recording on the nursing notes is signed by the nurse making it.
 The signature includes the name and title; for example, “NYAKUNDI .N
BSCN”. For UEAB students you are expected to write your surname,
followed by an initial of the English name, then student nurse (SN), and
institution (UEAB). E.g. For Nyakundi Nover , the signature would be
Nyakundi N. SN/UEAB. With computerized charting, each nurse has his or
her own password, which allows the documentation to be identified.
•
• 8. Spelling
 Use correct spelling while documenting.
 Correct spelling is essential for accuracy in recording. If unsure how to spell
a word, look it up in a dictionary or other resource.
 • 9. Accuracy
 The client’s name and identifying information should be written on each page of
the clinical record. Before making any entry, check that it is the correct chart.
 Do not identify charts by room number only; check the client’s name and hospital
number Special care is needed when caring for clients with the same name.
 When a recording mistake is made, draw a single line through it to identify it as
erroneous with your initials or name above or near the line (depending on agency
policy). Do not erase, blot out, or use correction fluid. The original entry must
remain visible.
 When using computerized charting, the nurse needs to be aware of the agency’s
policy and process for correcting documentation mistakes.
 Write on every line but never between lines. If a blank appears in a notation, draw
a line through the blank space so that no additional information can be recorded at
any other time or by any other person, and sign the notation
• 10. Sequence
• Document events in the order in which they occur for
example, record assessments, then the nursing interventions,
and then the client’s responses.

• 11. Appropriateness
• Record only information that pertains to the client’s health
problems and care. Any other personal information that the
client conveys is inappropriate for the record. Recording
irrelevant information may be considered an invasion of the
client’s privacy
 • 12. Completeness
Not all data that a nurse obtains about a client can be recorded.
However, the information that is recorded needs to be complete and
helpful to the client and health care professionals. Nurses’ notes need
to reflect the nursing process. Record all assessments.
•
• 13. Conciseness
Recordings need to be brief as well as complete to save time in
communication.
Repeated usage of the client’s name and the word client are omitted.
 • 14. Legal prudence
Accurate, complete documentation should give legal
protection to the nurse, the client’s other caregivers,
the health care facility, and the client.
Admissible in court as a legal document, the clinical
record provides proof of the quality of care given to a
client. For the best legal protection, the nurse should
not only adhere to professional standards of nursing
care but also follow agency policy
DOCUMENTATION SYSTEMS
• The main methods of charting are:
• Narrative Charting;
• Source-Oriented Charting;
• Problem-Oriented Charting;
• PIE Charting;
• Focus Charting;
• Charting by Exception (CBE);
• Computerized Documentation;
• Case Management with Critical Paths:
• Narrative Charting
• Describes the client’s status,
interventions and treatments; response to
treatments in a story format. Narrative
charting is now being replaced by other
formats. Chronological order is
frequently used.
• Source-Oriented Charting
• Narrative recording by each member (source) of the health care
team on separate records. For example, the admission department
has an admission sheet, nurses use the nurses’ notes, physicians
have a physician note.
•
• Problem-Oriented Charting OR problem-oriented medical
record (POMR)
• Uses a structured, logical format called S.O.A.P. - S: subjective
data - O: objective data - A: assessment (conclusion stated in a
form of nursing diagnoses or client problems) - P: plan. Uses
flow sheets to record routine care. SOAP entries are usually
made at least every 24 hours on any unresolved problem.
• Over the years, the SOAP format has been modified. The acronyms
• SOAPIE and SOAPIER refer to formats that add interventions,
evaluation, and revision:
• 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
evaluation.
• Changes may be made in desired outcomes, interventions, or target
dates.
• PIE Charting
• P: Problem statement
• I: Intervention
• E: Evaluation
• Example:
• P: Patient reports pain at surgical incision as 7/10 on 0 to
10 scale
• I : Given morphine 1mg IV at 23:35.
• E : Patient reports pain as 1/10 at 23:55.
 • Focus Charting
A method of identifying and organizing the narrative documentation
of all client concerns. Uses a columnar format within the progress
notes to distinguish the entry from other recordings in the narrative
notes (Date & Time, Focus, Progress note). The progress notes are
organized into: Data (D), Action (A), Response (R).
Example of focus charting Date & Time Focus: Progress notes: 09.
Sep.209 Acute pain related to surgical incision D: Patient reports pain
as 7/10 on 0 to 10 scale. A: Given morphine 1mg IV at 2335. R:
Patient reports pain as 1/10 at 2355.
 • Charting by Exception (CBE)
• The nurse documents only deviations from pre-established
norms (document only abnormal or significant findings).
Avoids lengthy, repetitive notes.

• Computerized Documentation
Increases the quality of documentation and save time.
Increases legibility and accuracy.
Facilitates statistical analysis of data.
 • Case Management with Critical Paths
A methodology for organizing client care
through an illness, using a critical pathway.
• A critical pathway is a multidisciplinary plan or
tool that specifies assessments, interventions,
treatments and outcomes of health-related
problems a cross a time line
ESSENTIAL CONCEPTS FOR
REPORTING CLIENT DATA
Reporting purpose is to communicate specific
information to a person or group of people.
Verbal communication of data regarding the client’s
health status, needs, treatments, outcomes, and
responses
Reporting is based on the nursing process.
Types of reports
• 1. Summary / Hand-Off Reports: Commonly occur at change of shift
(or when client care is transfers to another health care provider).
• 2. Walking Rounds: Occur in the client’s room; Include Nursing,
physician, interdisciplinary team.
• 3. Incident or Occurrence Reports: Used to document any unusual
occurrence or accident in the delivery of client care.
• 4. Telephone Reports and Orders: Report transfers, communicate
referrals, obtain client data, solve problems, inform a physician
and/or client’s family member regarding a change in the client’s
condition. Telephone orders are documented in the nurses’ progress
notes and the physician order sheet.
Commonly Used Abbreviations. TABLE 15–4
Kozier
• EXAMPLE • ad lib As desired
• Abd Abdomen • neg Negative
• MEDS Medications • ADL Activities of daily living
• ABO The main blood group
system
• mL Milliliter
• ac Before meals
• mod Moderate