Did you know that improper documentation can cause errors in the health care settings that could led to patients having adverse reactions or worst death? Nurse instructors always stress out how important to do documentation correctly. This is the reason why, clinical instructors keep on asking for revision on practice documentations done by students.
So why do nurses need to document? Documentation is a critical part of client care. Through the written records, client well-being is monitored and at the same time, care provided is communicated to other members of the health care team. During care and in the event of any investigations, it is accessed by the health care staff.
Standards of nursing documentation varies from one institution to another. However, regardless of the format, it should met the standards set. Clear and accurate documentation is essential in determining the quality of nursing care provided. Nurses are LEGALLY accountable to make sure their documentation meets the practice standards. Documentation is a legal requirement, hence, nurses should do it right.
To document a client’s progress, narrative notes, flowsheets, and discharge summaries are used. To communicate client problems clearly, narrative notes often come in special formats depending on the health institution. There are two types of charting in nursing, the first one is narrative charting, and the other one focus charting. Narrative charting is often taught to student nurses at the beginning then they move on to focus charting. The difference between the two is the amount of data charted. The latter type only includes important events and is supported by other forms of documents like the graphic sheet.
Some of the commonly used formats for charting are SOAP (Subjective, Objective, Assessment, Plan), SOAPIE (Subjective, Objective, Assessment, Plan, Intervention, Evaluation), DAR (Data, Action, Response), ADPIE (Assessment, Diagnosis, Planning, Intervention, Evaluation) and DEAR (Data, Evaluation, Action, and Response). Regardless of the type, these notes are critically important portions of the client’s record.
The acronym system makes it easy to remember the important points to include in the documentation. Although these formats may look different, the logic for writing the progress notes in all of them is similar to that of the nursing process. The client is assessed for data or assessment part, then a diagnosis or conclusion is made and the plan of care follows.
ADPIE Charting for Nurses
To understand how to write progress reports using adpie format lets discuss each component in detail:
A – Assessment
‘A’ stands for Assessment. Included in this area are the subjective and objective data supporting the identified problem. When you say ‘subjective’ assessment it refers to what your client said. Example of a subjective data is the client telling the nurse, ‘My stomach hurts on the lower right side.’ ‘Objective’ data, on the other hand, refers to the cues the nurse observed in the client. For example, the nurse observed a facial grimace to the client when he touches the lower right side of his stomach, this ‘objective’ cue can communicate to the nurse that the client is in pain.
When assessing the client, the nurse should steer clear from giving conclusions like, ‘I think the client is in pain.’ Recall what the client said or what you observed that supports your identified problem.
D – Diagnosis
‘D’ stands for Diagnosis. After the assessment data are gathered, the nurse analyzes the information and identifies the health problems for the client. Diagnosis provides direction to what interventions should be used for the client. This part of the charting is usually stated in a two-part format accepted by the North American Nursing Diagnosis Association (NANDA) – the diagnostic statement followed by the statement of the relating factor. An example of diagnosis is: Altered nutrition: high risk for less than body requirements (diagnostic statement) r/t chronic diarrhea for 3 weeks (relating factor).
P – Planning
‘P’ stands for Planning. Depending on the assessment, a plan of care is developed. Plans may include specific orders designed to manage the problem of the client, collect additional data about the problem and the goals of care. For example if the client is in pain, your plan may include: describe nonpharmacological methods to relieve pain and for the client to verbalize pain relief at the end of care.
I – Intervention
‘I’ stands for Intervention. These refers to the actions taken by the nurse relevant to the presented problem. For instance, if client is in pain, the nurse will inform doctor of the client complaint and administer prescribed medications.
E – Evaluation
‘E’ stands for Evaluation. In this area the nurse evaluates the response of the client to the interventions performed.
One important thing to remember in charting is to always include the name of the client and the date of documentation in each note. Also, make your writing as legible as possible so others can read it. Another thing is to write your name at the end of each note and sign it. This would communicate interventions were done during your shift, otherwise, other health care personnel would think an intervention was not performed. Remember, in the health care field if it was not documented it was not done!