The Nursing profession involves legalities when it comes to caring clients in all groups. These legal issues can only straighten when there is accurate documentation. The common term used in the field of nursing when it comes to documentation is charting. Though nurses may fill up many forms in each working day, the most integral part of the nurses’ responsibility is the charting for nurses.
Purpose of Charting
- It is a permanent record of patient’s information.
- Tracks the progress of the patient’s condition during the hospitalization as well as the status upon discharge. It serves as an information sheet of the medications and procedures rendered to the patient.
- Legal evidence for cross examination whenever complaints or malpractice claims have been sighted out.
- It serves as the evidence of continuity of care.
- It serves as a research material for retrospective study.
Types of Charting
1. Narrative Charting – This is the traditional form of charting. It is a source-oriented record wherein each medical personnel make documentation on the patient’s record in separate section. The advantage of using this type of recording is the provision of organized section for each member of the health care team. The disadvantage in using this type of recording is that the information is scattered throughout the chart. Review of history and accurate endorsements must be done.
Initial Nursing Assessment
2. Problem-oriented record – This was introduced by Lawrence Weed in the 1960s in order to give focus on the problems that patients face. With the problems listed, each medical personnel can contribute and collaborate on the plan of care. The advantage seen in this type of charting is collaboration among medical personnel. The disadvantage here is that it takes complete and on time assessment of problem lists.
The problem-oriented record is composed of the following: database, problem list, plan of care, progress notes.
Contents of progress notes
1. SOAP format – This format is usually used since it gives a quick look at the observation of each nurse as well as the nursing action on each observation.
S – Subjective data includes the patient’s complaints or perception of the present problem sited.
O – Objective data includes the nurse’s observation using his or her clinical eye
A-Assessment includes the inference made by the nurse from the two types of data. This is the part wherein the problem is stated. The nursing problem is stated in a form of nursing diagnoses using the NANDA.
P – Plan this includes the nursing actions to be made in order to solve the stated problem. This part can be revised.
SOAPIE or SOAPIER
I – Intervention –This is the part wherein specific nursing actions are stated
E – Evaluation –This is the part wherein the nurse evaluates the reaction of the patient or progress of the problem being solved.
R-Revision – This is the section that states the changes made in order to further resolve the problem.
Case: A patient with hypersensitivity reaction secondary to food intake.
S – “My skin is so itchy, especially on the skinfolds.”
O – Skin appears to be flushed with bumps. Irritation noted on the armpit and inner thighs.
A – Altered comfort secondary to food intake
P – Inform the patient not to scratch the skin.
– Apply cold compress on the hot spots
– Cut nails in order to prevent skin scratches
– Refer to the physician
-Assess for progress of skin rash
I – Instructed not to scratch the skin.
-Cut the fingernails short
-Applied cold compress
–Referred to the physician
E – “I feel more comfortable and I do not have the urge to scratch my skin.”
R – Give antihistamine (Antamin) 1mg/mL as deep intramuscular injection to left deltoid muscle.
3. Focus Charting – This type of charting involves Data, Action and Response category. This is a client-focused charting. Since it the client being talked about most of the documentation, this is a form of holistic perspective of client’s needs.
D – Facial grimacing, graded the nape pain as 7 in the scale of 1 to 10 with 10 as severe pain
A – Given Norgesic Forte per orem as now dose.
R – Rated pain as 2 and able to walk on her own.
Guidelines in charting
1. Precision – As a nurse, precision is the key to clear understanding between colleagues as well the legalities that surround the charting. Being precise means being specific when it comes to describing the observations done, on the other hand, being accurate must also give factual and measurable units. The accuracy also involves the time element which an important part of sequencing the events.
2. Objectivity – As a nurse, you are trained to use terms that stated objective data and not mere opinions. Viewpoints or hunches are not accepted in charting. This means you are trying to seclude your emotions from the observation. In this way, transparency can be achieved in documenting the happenings throughout the nursing care.
3. Write in print –Writing is print means that you are stating the events clearly. In this manner, you are not the only who can understand the hand writing but rather be more readable among quality assurance personnel. The only time that you can write in script is during the signature portion. This is signifies that you are the one who took responsibility of the patient as well as documenting the type of care the client received.
Charting for nurses involves a lot terms that must be understood by the nursing community. In charting, it is better for nurses to be accurate and précised in making observations as an effective tool in giving holistic type of nursing care.