Kozier & Erb's
Fundamentals of Nursing
Concepts, Process, and Practice
Eleventh Edition
Guidelines/ Protocols/
Tools in Reporting
Related to Client Care
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DOCUMENTATION SYSTEMS
-Source-Oriented Record,
-Problem-Oriented Medical Record,
-Problems, Interventions, Evaluation
(PIE) model,
-focus charting,
-charting by exception (CBE),
computerized documentation, and
case management.
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DOCUMENTATION SYSTEMS
•These documentation systems can be
implemented using traditional paper
forms or EHRs.
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Source-Oriented Record
•Traditional client record.
•Each person or department makes
notations in separate sections of the
client’s chart.
•Information about a particular problem
is distributed throughout the record.
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Narrative Charting
•a traditional part of the source-oriented
record.
•It consists of written notes that include
routine care, normal findings, and client
problems.
•The information has no right or wrong
order, although chronologic order is
frequently used.
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Narrative Charting
•When using narrative charting, it is vital
to organize the information clearly and
coherently.
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Narrative Charting
•When using narrative charting, it is vital
to organize the information clearly and
coherently.
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SOR: Advantages and Disadvantages
•Advantages:
-convenient
-easy to trace the information specific to
one’s discipline.
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SOR: Advantages and Disadvantages
Disadvantages:
-Information about a particular client’s
problem is scattered throughout the
chart.
-Decreased communication among the
health team,
-incomplete picture of the client’s care,
and a lack of coordination of care
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A narrative note in an EHR.
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Problem-Oriented Medical Record
(POMR) or Problem-Oriented
Record (POR)
-established by Lawrence Weed in
the 1960s.
-The data are arranged according to
the problems the client has rather
than the source of the information.
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Problem-Oriented Medical Record
(POMR) or Problem-Oriented
Record (POR)
-Members of the health care team
contribute to the problem list, plan of
care, and progress notes.
-Plans for each active or potential
problem are drawn up, and progress
notes are recorded for each problem.
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Advantage of POMR:
a. encourages collaboration
b. the problem list in the front of the
chart alerts caregivers to the client’s
needs and makes it easier to track
the status of each problem.
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Disadvantage of POMR:
a. caregivers differ in their ability to use
the required charting format,
b. takes constant vigilance to maintain
an up-to-date problem list, and
c. somewhat inefficient: assessments
and interventions that apply to more
than one problem must be repeated.
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4 Basic Components of POMR:
•Database
•Problem list
•Plan of care
•Progress notes.
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DATABASE
•The database consists of all information
about the client when the client first
enters the health care agency.
-nursing assessment,
-primary care provider’s history,
-social and family data, and the results of
the physical examination and baseline
diagnostic tests.
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DATABASE
•Data are constantly updated as the
client’s health status changes.
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PROBLEM LIST
•Derived from the database.
•It is usually kept at the front of the chart
and serves as an index to the numbered
entries in the progress notes.
•Problems are listed in the order in which
they are identified, and the list is
continually updated as new problems
are identified and others resolved.
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An example of a problem list in the POMR in an
EHR.
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PLAN OF CARE
•The initial list of orders or plan of care is
made regarding the active problems.
•Care plans are generated by the
individual who lists the problems.
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PLAN OF CARE
•Primary care providers write physician’s
orders or medical care plans; nurses
write nursing orders or nursing care
plans.
•The written plan in the record is listed
under each problem in the progress
notes and is not isolated as a separate
list of orders.
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PROGRESS NOTES
•A progress note in the POMR is a chart
entry made by all health professionals
involved in a client’s care; they all use
the same type of sheet for notes.
• Progress notes are numbered to
correspond to the problems on the
problem list and may be lettered for the
type of data.
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S O A P Format
•Subjective data,
•Objective data,
•Assessment, and
•Planning.
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SOAP
•Subjective data consists of
information obtained from what
the client says.
•It describes the client’s
perceptions of and experience
with the problem
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SOAP
•Objective data consists of
information measured or observed
by the senses (e.g., vital signs,
laboratory, and x-ray results).
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SOAP
•Assessment is the interpretation or
conclusions of subjective and objective
data. During the initial assessment, the
problem list is created from the
database, so the “A” entry should be a
statement of the problem.
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SOAP
•In all subsequent SOAP notes for that
problem, the “A” should describe the
client’s condition and level of
progress rather than merely restating
the diagnosis or problem.
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SOAP
•The plan is the plan of care
designed to resolve the stated
problem. The initial plan is written by
the person who enters the problem
into the record. All subsequent
plans, including revisions, are
entered into the progress notes.
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SOAPI E/R
•Over the years, the SOAP format
has been modified. The
acronyms SOAPIE and
SOAPIER refer to formats that
add interventions, evaluation,
and revision:
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SOAPI E/R
•Over the years, the SOAP format
has been modified. The
acronyms SOAPIE and
SOAPIER refer to formats that
add interventions, evaluation,
and revision:
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SOAPI E/R
•Interventions refer to the specific
interventions performed by the
caregiver.
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SOAPI E/R
•Evaluation includes client responses to
nursing interventions and medical
treatments. This is primarily
reassessment data.
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SOAPIE/R
•Revision reflects care plan
modifications suggested by the
evaluation. Changes may be made in
desired outcomes, interventions, or
target dates.
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•Newer versions of this format
eliminate the subjective and
objective data and start with
assessment, which combines the
subjective and objective data.
•The acronym then becomes AP,
APIE, or APIER.
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An example of a SOAP note in an
EHR.
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PIE
•The PIE documentation model groups
information into three categories.
•PIE is an acronym for problems,
interventions, and evaluation of
nursing care.
•This system includes a client care
assessment flow sheet and progress
notes.
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FLOW SHEET
•uses specific assessment criteria in
a particular format, such as human
needs or functional health patterns.
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FLOW SHEET
•The time parameters for a flow sheet
can vary from minutes to months.
•In a hospital intensive care unit, for
example, a client’s blood pressure may
be monitored by the minute, whereas in
an ambulatory clinic, a client’s blood
glucose level may be recorded once a
month.
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•After the assessment, the nurse
establishes and records specific
problems on the progress notes, often
using NANDA diagnoses to word the
problem.
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•If there is no approved nursing
diagnosis for a problem, the nurse
develops a problem statement using
NANDA International’s three-part format:
-client’s response,
-contributing or probable causes of the
response, and
-characteristics manifested by the client
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•The problem statement is labeled “P”
and referred to by number (e.g., P #5).
•The interventions employed to manage
the problem are labeled “I” and
numbered according to the problem
(e.g., I #5).
•The evaluation of the effectiveness of
the interventions is also labeled and
numbered according to the problem
(e.g., E #5).
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•Advantage of PIE:
The PIE system eliminates the
traditional care plan and incorporates
an ongoing care plan into the
progress notes. Therefore, the nurse
does not have to create and update a
separate plan.
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•Disadvantage of PIE:
The nurse must review the nursing
notes before giving care to
determine current problems and
effective interventions.
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FOCUS CHARTING
•intended to make the client and
client concerns and strengths the
care focus.
•Three columns for recording are
usually used: date and time,
focus, and progress notes.
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FDAR
•The focus may be a condition, a nursing
diagnosis, a behavior, a sign or
symptom, an acute change in the client’s
condition, or a client’s strength.
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FDAR
•The progress notes are organized into
(D) data, (A) action, and (R) response,
referred to as DAR.
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FDAR
•The data category reflects the
assessment phase of the nursing
process and consists of observations of
client status and behaviors, including
data from flow sheets (e.g., vital signs,
pupil reactivity).
•The nurse records both subjective and
objective data in this section.
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FDAR
•The action category reflects planning
and implementation and includes
immediate and future nursing actions.
•It may also include any changes to the
plan of care.
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FDAR
•The response category reflects the
evaluation phase of the nursing process
and describes the client’s response to
any nursing and medical care.
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FOCUS CHARTING SYSTEM
•The focus charting system provides a
holistic perspective of the client and
needs. It also provides a nursing
process framework for the progress
notes (DAR).
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FOCUS CHARTING SYSTEM
•The three components do not need to be
recorded in order, and each note does
not need to have all three categories.
•Flow sheets and checklists are
frequently used on the client’s chart to
record routine nursing tasks and
assessment data.
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FOCUS CHARTING SYSTEM
•The three components do not need to be
recorded in order, and each note does
not need to have all three categories.
•Flow sheets and checklists are
frequently used on the client’s chart to
record routine nursing tasks and
assessment data.
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CHARTING BY EXCEPTION
•Charting by exception (CBE) is a
documentation system in which only
abnormal or significant findings or
exceptions to norms are recorded.
CBE incorporates three key elements
(Guido, 2010)
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CHARTING BY EXCEPTION
1. Flow sheets.
Examples:
A. graphic records of a vital sign sheet,
B. a head and face assessment in a
daily nursing assessment record, and
C. a Braden assessment of the skin.
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CHARTING BY EXCEPTION
2. Standards of nursing care
Documentation by reference to the
agency’s printed standards of nursing
practice eliminates much of the
repetitive charting of routine care.
An agency using CBE must develop its
specific standards of nursing practice
that identify the minimum criteria for
client care regardless of clinical area.
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CHARTING BY EXCEPTION
3. Bedside access to chart forms
In the CBE system, all flow sheets are
kept at the client’s bedside to allow
immediate recording and to eliminate
the need to transcribe data from the
nurse’s worksheet to the permanent
record.
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ADVANTAGES OF CBE
-Eliminates lengthy, repetitive notes
-makes changes in client condition
more prominent.
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DISADVANTAGES OF CBE
-the presumption that the nurse did
assess the client and determined what
responses were normal and abnormal.
-Many nurses believe in the saying “not
charted, not done” and may feel
uncomfortable with the CBE
documentation system.
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DISADVANTAGES OF CBE
-One suggestion is to write N/A on flow
sheets where the items are not
applicable and to not leave blank
spaces.
-This would then avoid the possible
misinterpretation that the nurse did not
do the assessment or intervention.
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COMPUTERIZED DOCUMENTATION
-Electronic Health Records
(EHRs) manage the massive
volume of information required in
contemporary health care.
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COMPUTERIZED DOCUMENTATION
-EHR can integrate all pertinent
client information into one record.
-Nurses use computers to store the
client’s database, add new data,
create and revise care plans, and
document client progress.
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COMPUTERIZED DOCUMENTATION
-Multiple flow sheets are not
needed in computerized record
systems because information
can be easily retrieved in
various formats.
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COMPUTERIZED DOCUMENTATION
-Computers make care planning and
documentation relatively easy. To
record nursing actions and client
responses, the nurse chooses from
standardized lists of terms or types of
narrative information into the computer.
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COMPUTERIZED DOCUMENTATION
-Computers make care planning and
documentation relatively easy. To
record nursing actions and client
responses, the nurse chooses from
standardized lists of terms or types of
narrative information into the computer.
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PROS
• Computer records can facilitate a focus on client outcomes.
• Bedside terminals can synthesize information from monitoring
equipment.
• Such systems allow nurses to use their time more efficiently.
• The system links various sources of client information.
• Client information, requests, and results are sent and received
quickly.
• Links to monitors improve the accuracy of documentation.
• Bedside terminals eliminate the need to take notes on a
worksheet before recording.
• Bedside terminals permit the nurse to check an order
immediately before administering a treatment or medication.
• Information is legible.
• The system incorporates and reinforces standards of care.
• Standard terminology improves communication.
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CONS
• Client’s privacy may be infringed on if security
measures are not used.
• Breakdowns make information temporarily
unavailable.
• The system is expensive.
• Extended training periods may be required when a
new or updated system is installed.
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Example of Variance Documentation
(Critical Pathway)
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Admission Nursing Assessment
•A comprehensive admission
assessment, also referred to as an
initial database, nursing history, or
nursing assessment, is completed
when the client is admitted to the
nursing unit.
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Admission Nursing Assessment
•These forms can be organized according
to health patterns, body systems,
functional abilities, health problems and
risks, nursing model, or type of health care
setting (e.g., labor and delivery, pediatrics,
mental health).
•The nurse generally records ongoing
assessments or reassessments on flow
sheets or on nursing progress notes.
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NURSING CARE PLANS
•Clinical records include evidence of
client assessments, nursing
diagnoses and/or client needs,
nursing interventions, client outcomes,
and evidence of a current nursing
care plan.
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NURSING CARE PLANS
•Depending on the records system
being used, the nursing care plan may
be separate from the client’s chart,
recorded in progress notes and other
forms in the client record, or
incorporated into a multidisciplinary
plan of care.
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2 Types of NCP
•Traditional Care Plan
•Standardized Care Plan
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Traditional Care Plan
• The traditional care plan is written for
each client. The form varies from
agency to agency according to the
needs of the client and the
department.
•Most forms have three columns: one
for nursing diagnoses, a second for
expected outcomes, and a third for
nursing interventions.
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Traditional Care Plan
• The traditional care plan is written for
each client. The form varies from
agency to agency according to the
needs of the client and the
department.
•Most forms have three columns: one
for nursing diagnoses, a second for
expected outcomes, and a third for
nursing interventions.
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Kardexes
•The Kardex is a widely used, concise
method of organizing and recording data
about a client, making information quickly
accessible to all health professionals.
•The system consists of cards kept in a
portable index file or on computer-generated
forms.
•The card for a particular client can be
quickly accessed to reveal specific data.
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Kardexes
•The Kardex may or may not become a
part of the client’s permanent record.
•In some organizations, it is a temporary
worksheet written in pencil for ease in
recording frequent changes in details of
a client’s care.
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Kardexes
• The information on Kardexes may be organized into sections, for
example:
• Pertinent information about the client, such as name, room number, age,
admission date, primary care provider’s name, diagnosis, and type of
surgery and date
• Allergies
• List of medications, with the date of order and the times of administration
for each
• List of intravenous fluids, with dates of infusions
• List of daily treatments and procedures, such as irrigations, dressing
changes, postural drainage, or measurement of vital signs
• List of diagnostic procedures ordered, such as x-rays or laboratory tests
• Specific data on how the client’s physical needs are to be met, such as
type of diet, assistance needed with feeding, elimination devices, activity,
hygienic needs, and safety precautions (e.g., one person assist)
• A problem list, stated goals, and a list of nursing approaches to meet the
goals and relieve the problems.
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Kardexes
•Whether the Kardex is a written paper or
computerized, it is essential to have a
place on it to record dates and the
initials of the person reviewing or
revising it. It is a quick visual guide to
ensure that information is current and
updated regularly.
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Flow Sheets
•enables nurses to record nursing data
quickly and concisely and provides an
easy-to-read record of the client’s
condition over time.
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GRAPHIC RECORD
•This record typically indicates body
temperature, pulse, respiratory rate,
blood pressure, weight, and, in some
agencies, other significant clinical data
such as admission or postoperative day,
bowel movements, appetite, and activity.
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INTAKE AND OUTPUT RECORD
•All fluid intake routes and fluid loss or
output routes are measured and
recorded on this form.
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MEDICATION ADMINISTRATION
RECORD
•Medication flow sheets usually include
designated areas for the date of the
medication order, the expiration date, the
medication name and dose, the
frequency of administration and route,
and the nurse’s signature.
•Some records also include a place to
document the client’s allergies.
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SKIN ASSESSMENT RECORD
•A skin or wound assessment is often
recorded on a flow sheet like the one
shown earlier in Figure 15–6.
•This EHR specifically utilizes the Braden
Assessment.
•EHRs may include categories related to
the stage of skin injury, drainage, odor,
culture information, and treatments
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PROGRESS NOTES
• Progress notes made by nurses provide information
about the progress a client is making toward
achieving desired outcomes.
• Include information about client problems and
nursing interventions.
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NURSING DISCHARGE/REFERRAL
SUMMARIES
•A discharge note and referral summary
are completed when the client is
being discharged and transferred to
another institution or to a home
setting where a visit by a community
health nurse is required.
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Documentation for the Nursing
Process
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