Methods for Documenting Nurses Notes
Narrative: The nurse may be asked to chart in chronological order the events that occur including the gathering of information. A sentence structure is usually preferred although the use of columns to organize the narrative may be used. There may be a separate column for treatments, nursing observations, comments, etc. Narrative charting is time consuming, so legibility is extremely important if the notes are to be understood by those reading them.
- Subjective data
- Objective data
Some facilities use the acronym SOAPIE in which Implementation (nursing actions or interventions) and Evaluation have been added. And then, there is SOAPIER in which Revision is the last component. Following each letter of the respective acronym used, the nurse is required to chart information relevant to that particular term.
It is a method, which condenses client data into fewer statements by combining subjective and objective data into the Assessment section and combining nursing actions (what the nurse will do) with the expected outcomes of client care (what the client will get or experience) into the Plan component.
The system consists of a 24-hour flow sheet combined with nursing progress notes. The notes are usually written as client problem statements using an approved nursing diagnosis. Problems are labeled P and given a number, nursing interventions are labeled I and evaluations of the nursing action or intervention are labeled E.
Flow Sheets: These are often called graphic records and are used as a quick way to reflect or show the client's condition. They are helpful records in documenting things such as vital signs, medications, intake and output, bowel movements, etc. The time parameters for a flow sheet can range from minutes to months. For example: In an intensive care unit a blood pressure might be recorded every five minutes while in a clinic setting a weight may be recorded only once a month.
Focus Charting: The term focus was coined to encourage nurses to view the client's status from a positive perspective rather than the negative focus in problem charting. The system uses three columns as indicated here. Note the information that is usually required in the third column titled Progress Notes (called the DAR):
Charting By Exception (CBE): This is a system of charting in which only significant findings or exceptions to standards or norms of care are recorded or charted. Flow sheets or charts are used in which check off marks are recorded. Recording an asterisk (*) means that a standard or norm of care was not implemented. The asterisk also means that a narrative nurses note has been charted to explain why the standard of care was not met or satisfied.
Regardless of the system of documentation that is used, nurses universally use or refer to the Nursing Process as a guideline when they are charting. The Nursing Process contains the following four phases of nursing care:
1. Assessment: observing the client for signs and symptoms that may indicate actual or potential problems.
2. Planning: developing a plan of care directed at preventing, minimizing or resolving identified client problems or issues.
3. Implementation: practicing the plan of care that has been developed; includes specific actions that the nurse needs to take to activate that plan.
4. Evaluation: determining whether the plan of care was effective in preventing, minimizing or resolving identified problems.
FACT Documentation System: The computer ready FACT system incorporates many CBE principles; it helps caregivers avoid documenting irrelevant information or repetitive notes and reduces the time spent in charting. The FACT format uses:
An assessment and action flow sheet: to document ongoing assessments and actions; normal assessment parameters for each body system are printed on the form along with planned actions. You can individualize the flow sheet according to your specific patient's needs.
A frequent assessment flow sheet: this is where you document vital signs and frequent assessments. On a surgical unit, for example, you would use a postoperative frequent assessment flow sheet.
Progress notes: require an integrated progress record; you would use narrative notes to chart the patient's progress and any significant events. As in FOCUS charting mentioned before, you would use the data-action- response method of charting.
Now that you've learned about nurses' documentation formats and methods, let's take a look at how nursing assistants document their care. Over time nursing assistant documentation has changed. Where once nursing assistants may have done some narrative charting, today charting is most often made on flow sheets or charts where only a check mark is required to indicate the care that has been provided. A Daily Nursing Care Record (see Appendix A) is one kind of flow sheet used by nursing assistants to document their daily care. Aspects of care such as the client's daily bath, oral, denture, and hair care appear on a preprinted form. All the nursing assistant has to do is check off the box next to the aspect of care after that care has been completed. Only rarely would the nursing assistant have to add a word or two of detail. An example might be in the recording of a bowel movement (BM), the nursing assistant may add whether or not the BM was small, moderate or large in amount.
It can be a tedious and time-consuming task for the nursing assistant to make sure that each and every box is either checked off or is recorded with a zero which indicates to anyone reviewing it that the care was not done for whatever reason. For example: the client may have refused the care; therefore, it could not be done.
Nursing assistants are required to immediately report care that was not done or was refused to their charge nurse or team leader. The nurse is then responsible for charting a narrative note as to why the care was not done as ordered. Although it is very time consuming for nursing assistants to check off or enter with a zero all the many boxes on the flow sheets provided for them to record care, it is important for the nurse to encourage and monitor their charting efforts. Remember, if absences appear on flow sheets, then legally care was not offered or provided. Since nursing assistants report to nurses, it is a nurse's responsibility to periodically monitor nursing assistant documentation for accuracy and completion. Randomly auditing nursing assistant documentation is an effective, continuous quality monitoring endeavor that, over time, could become a rewarding nursing assistant activity. But first, nurses need to ensure that nursing assistants have the time available to them so that they can accomplish the level of charting that is expected of them.
Performing random quarterly reviews of all nursing documentation should be an annual goal in all facilities considering the legal ramifications of absent or faulty documentation. Doing random auditing of records indicates that there is a healthy concern about charting accuracy and completion.