Documentation, Charting and

Reporting
NURS 212 Nursing Process II

Presented by:
Denyce Watties-Daniels, RN MS
Assistant Professor
Coppin State University

02/19/23 Denyce Watties-Daniels, RN MS 1

 Introduction
After reviewing this presentation, completing the
outline given in class and reading associated
information in your textbook:
Identify the types of medical records.
Discuss the various methods of charting.
Discuss the general rules for charting.
Describe essential information to be included in
a verbal client report.

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 The Purpose of Charting
To communicate information about the
client to members of the health care team

To maintain an accurate & comprehensive

record of the client’s health care

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 The Chart
Is a legal document that can be used as
evidence into court
Contains confidential information and must
be secured
Can be used as a source of information in
research
Is a comprehensive record of the client’s
plan of care
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 Confidentiality in Charting
Security of the chart is
essential
Keep documents in a
secure & restricted place
Avoid unauthorized
access via computer
Only individual giving
direct care to the client
should have access to the
chart

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 Types of Records
Problem Oriented Medical Record
(POMR)
Uses a universal problem list
Associated with the use of SOAP Notes
All members of the healthcare team document
in same progress notes
Most often used in nursing homes,
rehabilitation or in extended care facilities
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 Types of Records
Source Oriented Medical Record
Information is divided and organized according
to service provided
Each discipline has a section-i.e. dietary,
respiratory, physical therapy
Decentralized charting
Uses narrative notes for documentation
Each discipline develops their own care plans
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 Types of Records
Most institutions will use a modified
version of either system

Many institutions will use a combination of

both systems

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 Methods of Charting
Narrative Notes

SOAP Notes

Check List-Charting by Exception

Each method has advantages and disadvantages

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 Narrative notes
Documentation uses
paragraph format

Widely used

Used in combination
with checklist

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 Example of Narrative Charting

“ Client is alert and oriented X 3. Denies pain

or discomfort. Ambulated to bathroom w/o
assistance. Voided 200cc of clear yellow
urine.”

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 Narrative notes
Advantages Disadvantages
Easy to write-no Often lacks detail
special format

Disorganized at times
Not limited to just a
discussion of the
client’s problems Does not reflect
nursing process
Can include test
results, etc.

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 Narrative Note Reminders
Organize note using
head-to-toe
assessment format.
Be specific-include
size, color shape,
characteristics of
information
documented
Use only approved
abbreviations
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 SOAP Notes
Associated with a
problem list in the
problem oriented
medical record
Organizes information
using the problem
solving method or
nursing process

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 SOAP Notes

Documentation divided into sections

S- Subjective information
O- Objective information
A- Assessment/Problem/Nursing Diagnosis
P- Plan of care

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 SOAP(IER) Notes
Improvements made to
format
Advanced to
“SOAPE” and
“SOAPIER” notes
Now includes
I-Implementation
E- Evaluation
R-Revision of plan

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 Example of SOAP Charting

S- “I feel fine. My leg doesn’t hurt anymore.”

O- Client able to ambulate w/o assistance to
bathroom. Rt. Leg with good pulse, pink no
swelling. No c/o pain.
A- Altered comfort-Pain
P-Continue to monitor client during
ambulation. Assess pedal pulses in rt leg

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 Examples of
SOAP(IER)Charting
SOAP (IER)
(SOAP- As previously written)
I- Contact physician and report findings.
E- Blood clot in leg improved. Client is pain
free
R- No revisions in plan.
.

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 SOAP Notes
Advantages Disadvantages
Follows nursing format May contain multiple
problems in one note
Contains a complete
summary of plan of May be difficult for
care some individuals to
write
Relates to specific Multiple notes make a
client problems lengthy chart entry

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 SOAP Note Reminders
Use a different note
for each problem
Do not attempt to put
multiple problems in
the same note
Use a nursing
diagnoses when
writing the “A-
assessment”.
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 Charting by Exception
Incorporates use of checklist to document
routine information
Significant information is documented
using a narrative note
Advantage- Quick and easy documentation
of information
Disadvantage- Many fail to make essential
narrative note entry.
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 Computerized Charting
Data entered using hand-
held devise or desk top
computer
Information can be
accessed by approved
individuals at remote sites
Saves time
User must have basic
computer knowledge

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 Rules of Charting
Use pen only-some
agencies may require
black pen only
Be objective-
document the facts not
your opinions
Use legible writing
with no spelling errors

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 Rules of Charting
Make entries timely-
document as you go, not
just at the end of the day
Do not erase or use white
out
Date, time and sign every
entry
Do not skip lines/spaces in
the progress notes
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Do not tear out or destroy
sheets
Do not recopy another’s
notes
Correct errors by drawing
a single line through the
entry, write “error” across
the top and add your
initials
Keep notes clear, pertinent
and concise
24
 Remember!
The chart is the property of the HOSPITAL or
AGENCY and not the client.

Special procedures are needed to give clients

access to their records

Family and friends, even if they are employees of

the agency, are not authorized to have access to
the client’s chart.

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 Reporting
Verbal communication of
pertinent client
information

Summary of significant
client information

Aides in consistency and

continuity in client care

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 Reporting
Include background
information about client
Primary medical and
nursing diagnoses
Recent medications and
treatments
Outcomes of interventions
Family/client concerns
Needed follow-up care

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 Reporting Reminders
Review your notes before beginning
Make sure you have essential information
present- lab data/ test results, kardexs
Speak clearly, concisely
Deliver the facts
Relate necessary follow-up care

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 Summary
Documentation, charting and reporting are
essential task of the nurse
Documentation, charting and reporting must be
accurate and complete to give a comprehensive
picture of the client
Measures must be initiated to secure client
information
Follow agency guidelines when documenting and
reporting client information.

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 THE END
This concludes the presentation on
Documentation, Charting and Reporting

Please refer to your textbook for further

information
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