The following examples demonstrate various forms and formats of documentation. Computerized templates of forms or hard copy pen-and-paper preprinted forms can be used, depending on the individual facility needs, resources, and requirements.
Documentation is an integrated component of the process of developing a nursing care plan that is initiated by the appropriate nursing personnel. The initial admission assessment is commonly the responsibility of an RN, but may be delegated to the LPN/LVN and co-signed by an RN. Nursing diagnoses (NANDAs) are integral parts of the nursing process and need to be reflected in your facility’s documentation and record-keeping formats. The basic nursing process consists of the assessment, identification of NANDAs, plans with specific goals, interventions or implementations, and the evaluation of each plan or goal. (Refer to Unit 6.)
For demonstration purposes, the abbreviated medical history below is appropriate for all examples (Figs. AppD 1-5). The NANDA diagnoses are developed from this medical history and from an initial comprehensive admission nursing assessment, which is not provided here. A fourth problem is identified by the nurse and is used for examples of charting formats.
Abbreviated Medical History
Ms. G. H. is a 74-year-old female who was admitted to an acute-care facility from a long-term care facility. Her history includes a cerebrovascular accident 2 years ago, resulting in weakness of the left leg. She was admitted to the acute care facility 2 days ago with a diagnosis of left lower lobe pneumonia.
1. Gas exchange impaired related to pneumonia as manifested by LLL crackles, admission temperature of 101° F, and pulse oximetry of 89% without supplemental O2
2. Acute confusion related to pneumonia and change in environmental surroundings as manifested by oxygen saturation of 89% and disorientation to time and place
3. At risk for impaired tissue integrity related to bed rest and lack of physical mobility
EXAMPLES OF NARRATIVE-CHRONOLOGICAL NURSES’ PROGRESS NOTES
In this example, a head-to-toe assessment by body system is used. The documentation is written as a narrative as the events occurred (ie, narrative chronological charting). Notice how the numbered NANDAs, from the abbreviated medical history above, are integrated into the assessment.
Figure AppD-1A addresses the three major NANDA diagnoses, which are numbered in the NANDA Diagnosis column. For instructional purposes using this example, the NANDA diagnoses are also in bold italics within the charting.
For our example of charting, the nurse completes an initial shift assessment. At the time of the collection of data, the nurse also discovers significant abnormal findings related to nausea, abdominal distention, and pain. A fourth NANDA is then developed relating to the newest priority (Fig. AppD-1B).
PROBLEM AREA (FOCUS) CHARTING
SOAP (Subjective, Objective, Analysis, Plan)
Each NANDA diagnosis would be documented with its own SOAP format. For this example, the focus will be on the new problem, NANDA #4.
APIE (Assessment, Problem, Implementation, Evaluation)
Each NANDA diagnosis would be addressed separately using the APIE format based upon the nursing assessment, the care plan, and the NANDAs. Here, the format of APIE is updated with the newest finding.
EXAMPLES OF SYSTEMS FLOW SHEET AND CHARTING BY EXCEPTION
With charting by exception, the nurse generally starts by working with a standard systems flow sheet (Fig. AppD-4A), which indicates most normal findings according to body system (neurologic, cardiovascular, and so forth) or other organized, preprinted format.
EXAMPLE OF GRAPHIC FLOW SHEET
Figure AppD-5 shows a graphic flow sheet that indicates multiple areas of routine charting.
FIGURE IA · Example of narrative-chronological nurses’ progress notes.
Nursing Diagnosis, continued and updated from original admission assessment:
4. Gastrointestinal tissue perfusion ineffective related to mechanical blockage of peristalsis as manifested by hyperactive bowel sounds RUQ, absent bowel sounds in remaining quadrants, and acute, severe abdominal pain and nausea. — M Kowalski, RN
*Note to student: An error in charting can be addressed by drawing a single line through the error and writing ERROR and your initials. Put this in parentheses. Other ways of documenting charting errors are to write recorded in error or mistaken entry and your initials.
FIGURE IB · The nurse has identified a new problem and added it to the nursing care plan.
FIGURE 2 · Example of problem area (focus) charting: SOAP (subjective, objective, analysis, plan).
FIGURE 3 · Example of problem area (focus) charting: APIE (assessment, problem, implementation, evaluation).
FIGURE 4A · Systems flow sheet.
FIGURE 4B · Charting by exception.
FIGURE 5 · Graphic flow sheet.