CHARTING FOR

NURSES
METHODS OF NURSING
DOCUMENTATION
IMPORTANCE OF DOCUMENTATION
• Nurses spend a lot of time charting/documenting throughout their
shifts.
• There is a saying amongst nurses, “if it wasn’t charted, then it
didn’t happen.”
• Nurses must document every single thing they do for their
patients throughout their shifts, including conversations and
communication.
• Primarily, documentation will consist of charting nursing
assessment findings and nursing interventions or cares, though
nurses also need to document phone calls with patients,
provider’s verbal orders, and anything out of the ordinary that has
happened throughout the shift.
• Doing so will help protect nurses as an employee and will ensure
that proper care is given to patients and communicated with other
caregivers and providers.
WHEN SHOULD YOU DOCUMENT?
• Different types of documentation are completed are
varying intervals.
• For example, some documentation, like fall risk or
physical assessments, only need to be done once a
shift. However, other assessments, such as for pain,
should be done regularly throughout the shift as
needed.
• Other regular documentation should be taken upon
intake, at the change of a shift, when a patient is
discharged, when they return from a test or procedure,
and any time a change in patient condition occurs.
• Some nurses find it difficult to set aside time routinely
during their shift to document, especially during shifts
that are busier than usual. However, it is a crucial part
of good nursing and quality patient care.
WHEN SHOULD YOU DOCUMENT?

• If you’re having a hard time remembering to

document or setting aside time for it, try
setting a timer or scheduling time for
yourself during a shift to spend at least 10
minutes documenting.
• It is easier to document as you go
throughout your shift, then try to remember
everything at the end of a long shift.
• Unfortunately, waiting until the very end of a
shift to do all the required documentation
can result in documentation errors.
OUTLINE
 Introduction
 Method of documentation
a. Narrative documentation
b. Problem-Orientated Medical Record (POMR)
c. SOAP/IER
d. The PIE notes
e. Focus Charting
f. Nursing diagnosis
g. Reference .
INTRODUCTION
Documentation
is not separate from care and it is not
optional. It is an integral part of registered
nurse practice, and an important tool that
RNs use to ensure high-quality client care.
The term “documentation” refers to: any
written or electronically generated
information about a client that describes
client status or the care or services provided
to that client.
METHOD OF DOCUMENTATION
Narrative documentation :
is the traditional method for recording nursing care
provided. It is a story-like format to document
information specific to client conditions and nursing
care.
Data are recorded in the progress notes without
an organizing framework. It often requires the
reader to sort through information to locate the
data required .
Guidelines :
METHOD OF DOCUMENTATION
Guidelines :
1. The initial entry and assessment, narrative notes
include all patient care activities such as diet,
hygiene, ambulation, elimination, visits from
health care professionals (Dr, dilatation, social
worker , etc) or family, tests, specific problems
2. All entry are signed and dated. Every timed entry
must have a legal signature: 1st initial, last name
and legal status.
3. The last entry on a page must have a legal
signature. Plan the last entry on a page so it has
a logical statement and signature.
4. Each page of narrative notes is a legal document
must be dated–and signed.
METHOD OF DOCUMENTATION
POMR - Problem-Orientated Medical Record
(POMR)
Recording data abut the health status of a patient -
a problem solving system the POMR preserves the
data in an easily accessible way that encourage
ongoing assessment and revision of the health
care plan by all members of health care team.
All data base is collected before beginning of
identifying the patient problem.
METHOD OF DOCUMENTATION
GENERAL CONCEPTS:
 gives emphasis to client’s perceptions of their
problems
 requires continuous evaluation and revision of the
care plan
 provides greater continuity of care among health-
care team members
 enhances effective communication among health-
care team members
 increases efficiency in gathering data
METHOD OF DOCUMENTATION
SOAP/IER :- SOAP/IER
One of the most prominent features of this problem- orientated
method of documentation is the structured way in which narrative
progress notes are written by all health- care team members,
using the SOAP, SOAPIE or SOAPIER format
Subjective the client’s observations
Objective the care provider’s observations and tests
Assessment the care provider’s understanding of the
problem
Plans goals, action, advice
Intervention when an intervention was identified
and changed to meet client’s needs
Evaluation how outcomes of care are evaluated
Revision when changes to the original
problem come from revised interventions,
outcomes of care or timelines this is used to
denote changes
To help with accurate and thorough documentation skills, try following the
SOAPIE method. There is an older version of SOAPIE notes, which are
SOAP notes.

Subjective –Documentation should include what the patient says or

information that only the patient can provide personally. This should include
perceived pain, symptoms such as feelings of numbness or tingling, medical
and family history, and allergies. This information is gathered through
asking the patient questions and is important to record exactly as the patient
reports.

Objective – Record what the nurse observes, hears, sees, and feels during
the patient assessment. The types of assessments performed is dependent on
the facility the patient is in (inpatient versus outpatient) and on the medical
diagnoses and patient complaints.
Analysis – After subjective and objective assessment data is collected, the
nurse should make an initial analysis of the patient’s condition and identify
any appropriate nursing diagnoses.
Plan – Once an initial nursing diagnosis has been identified, the
nurse must create a plan of action. This may include repositioning,
requesting pain medication from the providers, applying oxygen
per protocol, or providing emotional support. The plan should be
patient-centered and based on the nursing diagnoses.
Implementation – After the plan of action has been decided, the
actions (interventions) should be put into motion. Sometimes, a
nurse’s plan does not go exactly as planned and that is to be
expected. It is important to document all of the interventions
performed, and even the ones that were attempted.
Evaluation – Finally, the outcomes of the interventions need to be
evaluated. The evaluation often includes reassessing the patient. If
the evaluation reveals that an intervention did not work, a different
plan may need to be made. Repeat the last few steps as necessary
until a satisfactory outcome is reached.
METHOD OF DOCUMENTATION
PIE
The PIE notes are numbered or labeled according to the client’s
problems. Resolved problems are dropped from daily
documentation after the RN’s review. Continuing problems are
documented daily (Potter et al., 2006 )
Problems
Intervention
Evaluation

FOCUS CHARTING
Focus Charting (sometimes referred to as DAR)
This method of documentation consists of notes that
include data, both subjective and objective; action or
nursing interventions; and response of the client.
Data
Action
Response
METHOD OF DOCUMENTATION
GENERAL CONCEPTS:
 gives emphasis to client’s perceptions of their
problems
 requires continuous evaluation and revision of the
care plan
 provides greater continuity of care among health-
care team members
 enhances effective communication among health-
care team members
 increases efficiency in gathering data
 NURSING
DIAGNOSIS
 Physical diagnosis
• diagnosis based on signs, symptoms, and laboratory findings
during life

Differential diagnosis
• the determination of which one of several diseases may be
producing the symptoms

TYPE OF medical diagnosis

• diagnosis based on information from sources such as findings
DIAGNOSIS from a physical examination, interview with the patient or
family or both, medical history of the patient and family, and
clinical findings as reported by laboratory tests and radiologic
studies

clinical diagnosis
• diagnosis based on information obtained by inspection,
palpation, percussion, and auscultation
WHAT IS NURSING DIAGNOSIS?
• Nursing diagnosis is a clinical judgment about individual,
family, or community responses to actual or potential health
problems/life processes.
• Nursing diagnosis provides the basis for selection of nursing
interventions to achieve outcomes for which the nurse is
accountable.
• a statement of a health problem or of a potential problem in
the client's health status that a nurse is licensed and
competent to treat.
• The process of assessing potential or actual health
problems, including those pertaining to an individual patient,
a family or community, that fall within the scope of nursing
practice; a judgment or conclusion reached as a result of
such assessment or derived from assessment data.
 Types and Components of Nursing Diagnoses
A. Problem-Focused Nursing Diagnoses / actual
 A problem-focused nursing diagnosis "describes human responses to
health conditions/life processes that exist in an individual, family, or
community.
 It’s referred to the recent problem that the patient is complaining from it.
 It is supported by defining characteristics (manifestations, signs, and
symptoms) that cluster in patterns of related cues or inferences"
(NANDA-I, 2009).
 This type of nursing diagnosis has four components: label, definition,
defining characteristics, and related factors.
 The label should be in clear, concise terms that convey the meaning
of the diagnosis.
 The definition should add clarity to the diagnostic label. It should also
help to differentiate a particular diagnosis from similar diagnoses.
  For problem-focused nursing diagnoses, defining characteristics
are signs and symptoms that, when seen together, represent the
nursing diagnosis. If a diagnosis has been researched, defining
characteristics can be separated into major and minor
designations.
Related Factors
o In problem-focused nursing diagnoses, related factors are contributing
factors that have influenced the change in health status. Such factors
can be grouped into four categories:
1. Pathophysiologic, Biologic, or Psychological. Examples include
compromised oxygen transport and compromised circulation.
Inadequate circulation can cause Impaired Skin Integrity.
2. Treatment-Related. Examples include medications, therapies,
surgery, and diagnostic study. Specifically, medications can cause
nausea. Radiation can cause fatigue. Scheduled surgery can cause
Anxiety.
Related Factors
o In problem-focused nursing diagnoses, related factors are
contributing factors that have influenced the change in health
status. Such factors can be grouped into four categories:
3. Situational. Examples include environmental, home,
community, institution, personal, life experiences, and roles.
Specifically, a flood in a community can contribute to Risk
for Infection; divorce can cause Grieving; obesity can
contribute to Activity Intolerance.

4. Maturational. Examples include age-related influences,

such as in children and the elderly. Specifically, the elderly
are at risk for Social Isolation; infants are at Risk for Injury;
and adolescents are at Risk for Infection.
To determine the presence of a problem-focused diagnosis, ask,
"Are major signs and symptoms of the diagnosis in this
person?"
 PROBLEM FOCUSED EXAMPLE
Acute Pain
• Labor and delivery is an extremely painful process, and the
duration and intensity vary for each individual. The pain is caused
by muscle contractions in the uterus and immense pressure on
the cervix. It will present itself as intense cramps in multiple parts
of the body, such as the abdomen, groin, and back.
• Nursing Diagnosis: Acute Pain
Related to:
• Muscle contractions
• Tissue trauma
As evidenced by:
• Restlessness
• Moaning, crying, wincing
• Verbalization of pain
• Facial mask of pain
• Diaphoresis
• Tachycardia and tachypnea
 PROBLEM FOCUSED EXAMPLE
Expected outcomes:
 Patient will verbalize a decrease in pain.
 Patient will show signs of being at ease and comfort, as
evidenced by resting and breathing even and unlabored.
 Patient will demonstrate and utilize practices that will help reduce
the pain, such as relaxation and breathing techniques and
changes in body positioning.
Assessment:
1. Assess the patient’s level of pain using the numeric pain scale.
Pain is always subjective. Finding out how much pain the patient
is experiencing is important to drive further interventions.
2. Screen pain along with assessing vital signs. Pain is often
considered the fifth vital sign. In addition to this, blood pressure,
pulse, and respiratory rates can elevate when experiencing pain.
PROBLEM FOCUSED EXAMPLE
Interventions:
1. Establish a rapport with the patient and their significant
other.
Entertaining any questions they may have will reduce
barriers in communication, ultimately easing any fears and
promoting trust and relaxation.
2. Instruct the patient on breathing techniques.
Breathing can help distract from pain. The nurse can
instruct on breathing techniques such as belly breathing or
pant-pant-blow breathing through contractions.
3. Discuss pain relief options.
The mother should be in charge of her labor plan. The
nurse can discuss and explain options for pain relief and
help the mother decide what is best for them.
PROBLEM FOCUSED EXAMPLE
Interventions:
4. Assist the patient in positioning.
Adjusting the body’s positioning will help limit fatigue and
enhance circulation. Allow the mother to decide which
positions relieve pain, such as side-lying, leaning, or on all
fours.
5. Provide comfort measures.
Back rubs, pillows for better positioning, and ice cubes can
provide short-term relief.
6. Administer analgesics if ordered.
An epidural can be placed to block pain below the waist.
The nurse assists the anesthesiologist with positioning and
preparing the site for epidural insertion in the lower back
 Types and Components of Nursing Diagnoses
B. Risk and High-Risk Nursing Diagnoses
 NANDA-1 defines a risk nursing diagnosis as "human responses to
health conditions/life processes that may develop in a vulnerable
individual, family, or community.
 This diagnosis indicates from the data, a strong likelihood that it will
occur if actions are not taken.
 The Risk diagnosis only has 2 parts. It can be used with any NANDA
diagnosis.
 The concept of "at risk" is useful clinically. Nurses routinely prevent
problems in people experiencing similar situations such as surgery or
childbirth who are not at high risk.
 For example, all postoperative individuals are at risk for infection. All
women post-delivery are at risk for hemorrhage.
 Thus, there are expected or predictive diagnoses for all individuals who
 Types and Components of Nursing Diagnoses

B. Risk and High-Risk Nursing Diagnoses

 Risk factors for risk and high-risk nursing diagnoses represent those
situations that increase the vulnerability of the individual or group.
These factors differentiate high-risk individuals and groups from all
others in the same population who are at some risk.
Related Factors
 The related factors for risk nursing diagnoses are the same risk factors
previously explained for problem-
 focused nursing diagnoses.
To determine the presence of a risk
diagnosis, ask, "Are major signs and NO
symptoms of the diagnosis found in this
person?"
VALIDATION OF RISK FACTOR

NO
YES

Do you suspect a problem

RISK NURSING may be present?
DIAGNOSIS

YES NO
Record "Risk for" before the diagnostic label
related to the risk factors. Example:
POSSIBLE NSG NO PROBLEM AT THIS TIME
DX
Collect more data to confirm MONITOR
or R/0
Risk for Pressure Ulcers related to
immobility and fatigue Record "Possible" before the diagnostic label.
Example:
Possible Feeding Self-Care Deficit
related to fatigue and IV in right hand
 RISK PROBLEM EXAMPLE
Risk for Infection
The risk of infection increases due to the ability of some pathogens
to invade after the rupture of amniotic membranes. Puerperal sepsis
is an infection in the genital tract that can occur after giving birth and
spread throughout the body.
Nursing Diagnosis: Risk for Infection
Related to:
• Repetitive vaginal examinations
• Rupture of amniotic membranes
• Fecal contamination
• Umbilical cord prolapse
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as
the problem has not yet occurred, and the goal of nursing
interventions is aimed at prevention.
 RISK PROBLEM EXAMPLE
Expected outcomes:
• The patient will verbalize signs and symptoms of infection to notify the
nurse and/or provider of.
• The patient will demonstrate keeping their environment clean, safe, and
aseptic.
• The patient will show no signs of infection.
Assessment:
1. Assess vaginal secretions and amniotic fluid.
If the secretions are tested using Nitrazine paper, an alkaline reaction
(blue) will confirm the presence of amniotic fluid. The color, odor,
amount, and character should be recorded. Discoloration and foul
odor will indicate possible infection as normal fluids should appear
clear, with some specks of vernix (protective layer on baby’s skin) and
lanugo (hair covering the baby’s body).
2. Monitor and record fetal heart rate.
A rate greater than 160 beats per minute (fetal tachycardia) may
indicate infection. Poor oxygenation may also occur, especially during
abnormal labor.
 RISK PROBLEM EXAMPLE
Assessment:
3. Monitor vital signs and white blood cell count.
An elevation of WBC count and abnormal vital signs can indicate infection
(maternal temperatures of 38℃/100°F or higher and a WBC count of more
than 18,000-20,000/mm³). There is an increased risk for intra-amniotic
infection (chorioamnionitis) within 4 hours of membrane rupture.
Interventions:
4. Limit vaginal examinations.
Repeated vaginal examinations increase the risk of introducing pathogens into
the vagina and birth canal.
5. Utilize aseptic technique during invasive procedures.
The use of aseptic technique will help in preventing and limiting the growth of
bacteria, such as during IV or urinary catheter insertions.
6. Demonstrate proper perineal care and good handwashing techniques.
Proper handwashing reduces the risk of infection. Proper perineal hygiene,
such as wiping from front to back after giving birth, will help lessen the
possibility of introducing pathogens into perineal lacerations. Keeping the site
clean after birth will also aid in faster wound recovery.
 RISK PROBLEM EXAMPLE
Interventions:
4. Administer antibiotics as prescribed.
The administration of antibiotics during labor is controversial as
the medication may affect the baby. Still, when needed, it may
protect against infection, such as in case of prolonged rupture of
membranes.
5. Administer oxytocin as prescribed.
Oxytocin is a natural hormone used to induce labor by causing the
uterus to contract. The longer it takes for the baby to come out, the
more susceptible the mother and the baby are to infections.
C. Possible Nursing Diagnoses/Potential Complication
 Possible nursing diagnoses are statements that describe a suspected
problem requiring additional data.
 This is also known as a collaborative diagnosis. This is a problem the
nurse cannot treat independently. Nursing care will focus on monitoring
and preventing the problem. A collaborative diagnosis can be written as
a one or two part statement.
 In scientific decision making, a tentative approach is not a sign of
weakness or indecision, but an essential part of the process. The nurse
should delay a final diagnosis until he or she has gathered and
analyzed all necessary information to arrive at a sound scientific
conclusion. Physicians demonstrate tentativeness with the statement
rule out (RIO).
 Nurses also should adopt a tentative position until they have completed
data collection and evaluation and can confirm or RIO.
Possible nursing diagnoses are two-part statements consisting of
1. The possible nursing diagnosis
2. The "related to" data that lead the nurse to suspect the diagnosis
 An example is Possible Disturbed Self Concept related to recent loss
of role responsibilities secondary to worsening of multiple sclerosis.
 When a nurse records a possible nursing diagnosis, he or she alerts
other nurses to assess for more data to support or RIO the tentative
diagnosis. After additional data collection, the nurse may take one of
three actions:
a. Confirm the presence of major signs and symptoms, thus labeling
a problem-focused diagnosis.
b. Confirm the presence of potential risk factors, thus labeling a risk
diagnosis.
c. Rule out the presence of a diagnosis (problem-focused or risk) at
this time.
D. Health-Promotion Nursing Diagnoses
 According to NANDA-1, a health-promotion nursing diagnosis is "a clinical judgment
of a person's, family's, or community's motivation and desire to increase well-being
and actualize human health potential as expressed in the readiness to enhance
specific health behaviors, such as nutrition and exercise.
 For an individual or group to have a health-promotion nursing diagnosis, two cues
should be present:
1) a desire for increased wellness
2) effective present status or function in that specific health behavior.
 For example, an individual can be wheelchair bound yet desire to enhance their
already good nutrition.
 Diagnostic statements for health-promotion nursing diagnoses are one part,
containing the label only. The label begins with "Readiness for Enhanced," followed
by the higher-level wellness that the individual or group desires (e.g., Readiness for
Enhanced Family Processes).
 Health-promotion nursing diagnoses do not contain related factors.
E. Syndrome Nursing Diagnoses
 Syndrome nursing diagnoses are an interesting development in nursing diagnosis.
They comprise a cluster of predicted actual or high-risk nursing diagnoses related to a
certain event or situation.
 In medicine, syndromes cluster signs and symptoms, not diagnoses. In nursing, a
cluster of signs and symptoms represents a single nursing diagnosis, not a syndrome
nursing diagnosis.

Writing Diagnostic Statements

Three-part diagnostic statements (problem-focused nursing diagnoses) contain the
following elements:

Problem related to Etiology as manifested by Signs and

Diagnostic label Contributing factors Symptoms
 In two-part and three-part diagnostic statements, related to reflects a relationship
between the first and second parts of the statement. The more specific that the
second part of the statement is, the more specialized the interventions can be.
 For example, the diagnosis Noncompliance stated alone usually conveys the negative
implication that the individual is not cooperating. When the nurse relates the
noncompliance to be contributing factors, however, this diagnosis can transmit a very
different message:
 Noncompliance related to negative side effects of a drug (reduced libido, fatigue),
as evidenced by "I stopped my blood pressure medicine.“
 Noncompliance related to inability to understand the need for weekly blood
pressure measurements, as evidenced by "I don 't keep my appointments if I'm
busy."