Charting Resources
Charting Resources
Healthcare team members are legally required to document the care they provide to CLient. In a court of law the rule of thumb used is, “If it wasn’t documented, it wasn’t done.” Documentation should be objective, factual, professional, and use proper medical terminology, grammar, and spelling. All types of documentation must include the date, time, and signature of the person documenting. Any type of documentation in the health record is considered a legal document and must be completed in an accurate and timely manner. Abbreviations should be avoided in legal documentation.
Documentation is used for many purposes. It is used to ensure continuity of care across healthcare team members and across shifts; monitor standards of care for quality assurance activities; and provide information for reimbursement purposes by insurance companies, and your provincial health authority. Documentation may also be used for research purposes or, in some instances, for legal concerns in a court of law.
Common Types of Documentation
Common formats used to document patient care include charting by exception (CBE), DAR/DARP/DAP/DAPE notes, narrative notes, SOAP/SOAPIER, APIE/APIED progress notes, patient discharge summaries, and Minimum Data Set (MDS) charting.
Source: Documentation & Documenting and Reporting
The information you put in a patient’s medical record should more or less track the therapeutic process. Your charting generally should include:
- Authorship Details: For example, the date/time the note was written, as well as your full name, credentials, and signature.
- Your Assessment of the Patient: This includes your interpretation of the findings and any diagnosis.
- Objective Data: What your assessment told you.
- Subjective Data: What the patient told you.
- Plan of Care: This includes modifications to an existing care plan, evaluation notes on how well the care plan is going, or self-care instructions for the patient.
- Interventions You Implemented: For example, any procedures or medications administered.
- Consultations or Referrals: This includes details about the provider’s name and affiliation.
Source: Charting
Be sure to follow the policies and regulations set out by your agency and/or professional body.
Please share any resources that you may have found useful in your practice!
Narrative Notes:
Narrative notes are like a running log of everything that happened with the Client during a particular shift. The benefits of narrative notes are that they’re straightforward, easy to do, and simple to follow.
Charting by Exception:
Instead of comprehensive note-taking, charting by exception (CBE) documents only things that are outside the norm. The beauty of CBE is that it takes significantly less time to do, giving nurses more time to focus on other tasks. This type of charting is often used in Continuing Care.
Checklists and Flow Sheets:
These pre-made templates (usually one to two pages when they’re printed out) list all the data, services, and measures relevant to a particular type of visit, assessment, or condition. They consist mainly of boxes to check and short, blank spaces to fill out, making them typically quicker and easier to fill out than, say, writing a long narrative.
SOAP Notes:
SOAP(IER) stands for “subjective,” “objective,” “assessment,” and “plan,” with some healthcare professionals choosing also to add “intervention,” “evaluation,” and “revision.” This format is used to guide them when they’re charting about a particular problem or medical condition, which is more often seen in acute care of physical rehabilitation.
PIE Notes:
Similar to SOAP(IER), PIE is a simple acronym you can use to document specific problems (P), as well as their related interventions (I) and evaluations (E). Healthcare professionals write down their assessment on a separate form or flow sheet in the patient’s chart and assign each individual problem a number. Every time they refer to that particular issue in the patient’s chart, they use that assigned number.
The whole process is problem-oriented like SOAP(IER) and covers much of the same ground, but it’s a little simpler to use.
Focus DAR Charting:
Focus charting uses the DAR process (i.e., “data,” “action,” “response”) to guide and organize nursing notes. Similar to problem-centered charting, DAR charting organizes notes by focus (thus the name) that can span health changes, patient concerns, or specific events, in addition to traditional medical problems.
MDS Charting:
The Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings.
Source: Nurse Charting 101
Describing Affect - Objectively describing encounter(s) with the Clients you support is vital. By reviewing the MSE and even more specifically, GABA (General Appearance, Behaviour, Attitude), professionals can better capture details relating to Clients' participation and engagement.
Resources for Documentation & Recreation Therapy:
Other Resources:
Attached Files
| File | Action |
|---|
| MSE Definitions.pdf | Download |
| SOAP_Notes_101.pdf | Download |
| Teaching_Resource_Mental_Status_Examination.pdf | Download |
Charting Resources
Charting Resources
Healthcare team members are legally required to document the care they provide to CLient. In a court of law the rule of thumb used is, “If it wasn’t documented, it wasn’t done.” Documentation should be objective, factual, professional, and use proper medical terminology, grammar, and spelling. All types of documentation must include the date, time, and signature of the person documenting. Any type of documentation in the health record is considered a legal document and must be completed in an accurate and timely manner. Abbreviations should be avoided in legal documentation.
Documentation is used for many purposes. It is used to ensure continuity of care across healthcare team members and across shifts; monitor standards of care for quality assurance activities; and provide information for reimbursement purposes by insurance companies, and your provincial health authority. Documentation may also be used for research purposes or, in some instances, for legal concerns in a court of law.
Common Types of Documentation
Common formats used to document patient care include charting by exception (CBE), DAR/DARP/DAP/DAPE notes, narrative notes, SOAP/SOAPIER, APIE/APIED progress notes, patient discharge summaries, and Minimum Data Set (MDS) charting.
Source: Documentation & Documenting and Reporting
The information you put in a patient’s medical record should more or less track the therapeutic process. Your charting generally should include:
Source: Charting
Be sure to follow the policies and regulations set out by your agency and/or professional body.
Please share any resources that you may have found useful in your practice!
Narrative Notes:
Narrative notes are like a running log of everything that happened with the Client during a particular shift. The benefits of narrative notes are that they’re straightforward, easy to do, and simple to follow.
Charting by Exception:
Instead of comprehensive note-taking, charting by exception (CBE) documents only things that are outside the norm. The beauty of CBE is that it takes significantly less time to do, giving nurses more time to focus on other tasks. This type of charting is often used in Continuing Care.
Checklists and Flow Sheets:
These pre-made templates (usually one to two pages when they’re printed out) list all the data, services, and measures relevant to a particular type of visit, assessment, or condition. They consist mainly of boxes to check and short, blank spaces to fill out, making them typically quicker and easier to fill out than, say, writing a long narrative.
SOAP Notes:
SOAP(IER) stands for “subjective,” “objective,” “assessment,” and “plan,” with some healthcare professionals choosing also to add “intervention,” “evaluation,” and “revision.” This format is used to guide them when they’re charting about a particular problem or medical condition, which is more often seen in acute care of physical rehabilitation.
PIE Notes:
Similar to SOAP(IER), PIE is a simple acronym you can use to document specific problems (P), as well as their related interventions (I) and evaluations (E). Healthcare professionals write down their assessment on a separate form or flow sheet in the patient’s chart and assign each individual problem a number. Every time they refer to that particular issue in the patient’s chart, they use that assigned number.
The whole process is problem-oriented like SOAP(IER) and covers much of the same ground, but it’s a little simpler to use.
Focus DAR Charting:
Focus charting uses the DAR process (i.e., “data,” “action,” “response”) to guide and organize nursing notes. Similar to problem-centered charting, DAR charting organizes notes by focus (thus the name) that can span health changes, patient concerns, or specific events, in addition to traditional medical problems.
MDS Charting:
The Resident Assessment Instrument-Minimum Data Set (RAI-MDS) 2.0 is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings.
Source: Nurse Charting 101
Describing Affect - Objectively describing encounter(s) with the Clients you support is vital. By reviewing the MSE and even more specifically, GABA (General Appearance, Behaviour, Attitude), professionals can better capture details relating to Clients' participation and engagement.
Resources for Documentation & Recreation Therapy:
Other Resources:
Attached Files
Related