There are several documentation systems used in healthcare to record patient data, either electronically or on paper. Some common systems include narrative charting, source-oriented charting, problem-oriented charting using the SOAP format, PIE charting, focus charting, charting by exception, computerized documentation, and case management using critical paths. Problem-oriented charting using the SOAP format is a structured approach that documents subjective data, objective data, assessment, and plan.

1. Methods Of Recording /
Documentation Systems
BY:
Mr. M.Shivananda Reddy

2. • There are several documentation systems for
recording patient data.
• Regardless whether documentation is entered
electronically or on paper, each health care
agency selects a documentation system that
reflects its philosophy of nursing.

3. Methods (styles) of documentation:
• Narrative Charting
• Source-Oriented Charting
• Problem-Oriented Charting
• PIE Charting
• Focus Charting
• Charting by Exception (CBE)
• Computerized Documentation
• Case Management with Critical Paths

4. • Narrative Charting
– Describes the client’s status, interventions and
treatments; response to treatments is in story
format.
– Narrative charting is now being replaced by other
formats.

5. • 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 notes, etc….

6. • Problem-Oriented Charting
– 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

7. Recently S.O.A.P. format is modified as
S.O.A.P.I.E.R for better reflecting the nursing
process
• S: subjective data
• O: objective data
• A: assessment (conclusion stated in a form of nursing
diagnoses or client problems)
• P: plan
.I – intervention (specific interventions implemented)
.E – evaluation. Pt response to interventions.
.R – revision. Changes in treatment.

8. • 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.

9. • 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).

10. • DATA – SUBJECTIVE OR OBJECTIVE THAT
SUPPORTS THE FOCUS (CONCERN)
• ACTION – NURSING INTERVENTION
• RESPONSE – PT RESPONSE TO INTERVENTION

11. .
Date & Time Focus: Progress notes:
09.june.2015 Acute pain related to
surgical incision
D: Patient reports pain as
7/10 on 0 to 10 scale.
A: Given morphine 1mg IV
at 23.35.
R: Patient reports pain as
1/10 at 23.55

12. • Charting by Exception (CBE)
– The nurse documents only deviations from pre-
established norms (document only abnormal or
significant findings).
– Avoids lengthy, repetitive notes.

13. • Computerized Documentation
– Increases the quality of documentation and save
time.
– Increases legibility and accuracy.
– Facilitates statistical analysis of data.

14. • Case Management Process
– A methodology for organizing client care through an
illness, using a critical pathway/ standardized care
plan.
– 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.