2. Outline :-
• Introduction
• Method of documentation
a. Narrative documentation
b. Problem-Orientated Medical Record (POMR)
c. SOAP/IER
D . The PIE notes
e. Focus Charting
• Nursing diagnosis
• Reference .
3. 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.
4. 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 .
5. 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.
6. POMR
Problem-Orientated Medical Record (POMR)
Recording data abut the health status of a
patient I 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
identifiying the patient problem .
7. 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
8. 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
9. SOAP/IER :-
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 time lines this is used to
denote changes
10. -: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
11. 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
12.
13. Type of Diagnosis
physical diagnosis
differential
diagnosis
medical diagnosisclinical diagnosis
diagnosis based on
information
obtained by
inspection,
palpation,
percussion, and
auscultation
the determination of
which one of several
diseases may be
producing the
symptoms
diagnosis based on
information from
sources such as
findings 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
diagnosis based on
signs, symptoms,
and laboratory
findings during life
14. Definition :-
• 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.
15. Type of nursing diagnosis :-
1- ACTUAL:
It’s referred to the recent problem that the patient is
complaining from it .
Example: Impaired gas exchange r/t status of secretions
associated with difficulty coughing up secretions from
fatigue .
1. Large amounts thick green-yellow sputum
2. Frequent coughing with expectoration of sputum
3. Crackles throughout both lung fields
4. O2 sat of 90 - 87% without oxygen
16. Type of nursing diagnosis :-
RISK:
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.
Example: Risk for falls r/t to unsteady gait
17. Type of nursing diagnosis :-
POTENTIAL COMPLICATION:
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.
Example:
P.C. of chronic obstructive pulmonary disease: respiratory
failure
18. REFERENCES :-
• CRNBC Practice Standard Documentation
• www.crnbc.ca/NursingPractice/Requirements.
aspx
• Meadows G. Nursing informatics: An evolving
speciality. Nursing Economic$ 2002;20(6):300–
301. [PubMed]
