Nursing Documentation Format

Documentation Format

SOAPIER Format

S-SUBJECTIVE.=What patient tells you. (ex. I have leg pain).

O - OBJECTIVE. = Wh at you observe(observe the leg for swelling/ injury and facial expressions).

A-ASSESSMENT.=The critical analysis and evaluation or judgement of the patient condition

P-PLAN. = What you are going to do.(plan for any nursing intervention to reduce pain, informing physician, giving medication and comfort position).

I - IMPLEMENTATION. = Specific interventions implemented like hot or cold fomentation, administration of medication etc.

E-EVALUATION. = Patient response towards nursing care(patient may say, I am feeling better, my leg pain is reduced).

R-REVISION. = Changes the treatment. (If the pain is not reduced modify the intervention).

APIE Charting

It is Similar to SOAP

·           A-Assessment

·           P-Problem Identification

·           I-Intervention

·           E-Evaluation

Focus Charting

Focused only on nursing diagnosis, patient problem, signs and symptoms. It has three components (DAR)

·           DATA – subjective or objective data that supports the focus

·           ACTION – nursing intervention

·           RESPONSE – Patient response to intervention

Ex:

·           D – complaining of pain at incision site , pain score: 7/10

·           A  –  Repositioned  for  comfort. ----Analgesics injection given.

·           R – Patient states pain reduced, “Feels Much Better.”

Computer-Assisted Charting

·           Notes always legible and easy to read

·           Quick communication among departments about patient needs

·           Many providers have access to patient’s information at one time

·           Can reduce documentation time.

·           Reimbursement for services rendered is faster and complete