Methods/Types of

Documentation
Week 9
Documentation – Power Point #2

1
Methods of Documenting

 source oriented records

- advantages – easy to find section
- disadvantage – fragmented

 problem oriented record (POR’s)

- advantages – all team members use same
record
- disadvantage – may focus too narrowly on pt
problems as opposed to wellness

2
S-O-A-P-I-E – a type of POR
 S = subjective - statement from client
 O = objective - measurable or observable data
 A = analysis – interpretations based on S and/or O –
could be a nursing diagnosis statement
 P = plan – what is to be done about the identified
problem(s)
 I = implementation – how the plan is was carried out
 E = evaluation – client’s response to the interventions
 R = revision – how the plan of care will be changed
based on “E”

3
4
 PIE Charting
Advantages – no separate plan of care, problems are
identified each shift or day and numbered, plan of
care is built into documentation process

Disadvantages – need to read all the nursing notes to find

out problems and interventions prior to providing
care

5
6
Focus Charting
 DAR, FAIR
- advantages – holistic emphasis on pt and pts
priorities
- disadvantages – may not be useful for documenting
all care

7
8
 FAIR charting

Focus – Assessment – Intervention – Response

Used at Lakeridge
- easy to use

9
Charting by Exception
 shorthand method of charting that uses
well defined standards of care
 only significant findings or “exceptions”
are documented
 less charting time needed
 more emphasis on significant findings
 standardized assessments
 better tracking of important pt
responses

10
 main disadvantage is difficulty
proving high quality care
 easy to become complacent and not
really pay attention to what you’re
documenting
 tick charting questionable from a
legal standpoint
 popular due to time constraints but
may not be the best from a legal
point of view

11
12
13
ADPIE…
SOAPIE…
&
FAIR…

14
 Practicing
Documentation

15
Practice charting… SOAPIE
and FAIR
 Mrs. Benson, 85 years of age, has a history of CHF.
Her V/S at 0830 are 37.6 - 54 – 24 – 180/90. She
states that she is having difficulty breathing, even
with minimal exertion. She is anxious and restless,
and is feeling very tired.

16
 Next Week

 Documentation Continues

17