Unit -5

Documentation and
reporting
METHODS/SYSTEMS OF
DOCUMENTATION
METHODS/SYSTEMS OF DOCUMENTATION
• Methods of Documentation are the different
ways healthcare workers write and organize
patient information to keep it accurate and easy
to find.
• 1. Narrative documentation
• 2. problem -oriented medical record ( POMR)
• 3. SOAPIER
• [Link] ( problem intervention evaluation )
• 5. Focus charting (DAR)
• [Link] by exception (CBE)
1. Narrative
Documentation:
•This is the traditional way
where nurses write a story
about the patient’s condition
and care in chronological
order. It’s not structured, so
the reader might need to go
through the notes to find key
Example for narrative
documentation:
• “Patient Sarah, 25 years old, admitted to the
emergency department with complaints of
severe abdominal pain and nausea that
began the previous night and has been
worsening. Reports no known allergies or
prior medical history. On assessment, patient
appears uncomfortable and slightly flushed.
Vital signs are Blood pressure 130/85 mmHg,
pulse 90 bpm, and temperature 100.4°F.
Administered pain relief medication as
prescribed and instructed patient to rest. Will
[Link]-Oriented Medical
Record (POMR)
•Problem-Oriented Medical Record
(POMR) is a method of documenting
patient care that focuses on
identifying and addressing the
patient’s problems. It organizes data
based on the problems or diagnoses
and ensures continuous evaluation
and communication among
healthcare team members.
POMR Components:
1. Database: All initial patient information (e.g.,
nursing assessment, medical history, physical
exam results).
2. Problem List: A list of identified patient
problems, updated regularly. Problems are listed in
order and can be resolved or redefined.
3. Plan of Care: The treatment plan for each
problem, including physician and nursing orders.
• 4. Progress Notes: Documentation by
healthcare professionals about the patient’s
progress, using a standard format (e.g., SOAP).
E.g. The SOAP format is frequently
used.
SOAP is an acronym for:
S-Subjective Data
O-Objective Data
A- Assessment
• P-Planning
i) Data base:
Patient Information:
Name: Sarah
Age: 25
Reason for Admission: Abdominal pain
and nausea
Admitted Ward: Emergency Department
Allergies: None
• Previous History: None
ii)Problem List:
1. Abdominal Pain (Problem #1)
2. Nausea (Problem #2)
• 3. Slightly Elevated Temperature
(Problem #3)
iii)Plan of Care:
• Problem #1: Abdominal Pain
-Physician’s Order: Administer pain relief
medication as prescribed.
-Nurse’s Order: Monitor pain levels every hour and
adjust medication as needed.
• Problem #2: Nausea
-Physician's Order: Monitor for signs of worsening
nausea, and administer anti-nausea medication if
needed.
-Nurse’s Order: Encourage small sips of water and
• Problem #3: Slightly Elevated
Temperature
•
• -Physician’s Order: Monitor vital signs every
hour and assess temperature changes.
-Nurse’s Order: Administer antipyretics as
prescribed if temperature exceeds 101°F.
iv)Progress Notes (SOAP Format):
S (Subjective Data):
Patient reports abdominal pain starting the previous
night, becoming more intense.
“I feel nauseous and I can’t seem to get comfortable.”

O (Objective Data):
BP: 130/85 mmHg
Pulse: 90 bpm
Temperature: 100.4°F
Patient appears uncomfortable and flushed.
A (Assessment):
The patient’s abdominal pain and nausea are likely
related to a gastrointestinal issue, but further
investigation is required to rule out infection. The
elevated temperature may suggest the onset of a mild
infection or inflammation. Continuous monitoring is
needed.

P (Plan):
Administer pain relief as prescribed.
Monitor vital signs every hour and reassess condition.
Encourage rest and observe for any additional
symptoms of infection.
Advantages of POMR:
• 1. Focuses on the patient’s problems.
• 2. Requires continuous evaluation of the care
plan.
• 3. Improves communication and care
continuity.
• 4. Increases efficiency in gathering patient
data.
• 5. Organizes information in chronological
order.
[Link]:
• The SOAPIER format is a way of documenting patient progress in
a structured manner, using the following sections:
• 1. SOAP: 2. SOAPIE: 3. SOAPIER:
• S: Subjective data S: Subjective data
• O: Objective data S: Subjective O: Objective data
• A: Assessment data
O: Objective data
A: Assessment
• P: Plan
A: Assessment P: Plan
P: Plan I: Intervention
I: Intervention E: Evaluation
E: Evaluation R: Revision
• 1. S – Subjective Data: Information the
patient shares about their experience and
feelings regarding their condition (e.g., “I’ve
had abdominal pain since last night, and it’s
been getting worse. I feel nauseous.”)
• 2. O – Objective Data: Facts that healthcare
workers observe or measure, like vital signs,
lab results, and physical exam findings (e.g.,
BP: 130/85 mmHg
Pulse: 90 bpm Temperature: 100.4°FPatient
appears uncomfortable, slightly flushed, and
3. A – Assessment: The healthcare provider’s
interpretation of the subjective and objective
data (e.g. The abdominal pain and nausea are
consistent with a possible gastrointestinal issue,
though further assessment and testing are
required. The patient is mildly febrile, which
may indicate an infection or inflammation.”).
• 4. P – Plan: The care plan to address the
problem (e.g., “Administer pain relief
medication as prescribed. Monitor vital signs
every hour. Advise the patient to rest and
avoid consuming”).
• 5. I – Intervention : The specific actions
taken by healthcare providers (e.g., “Pain
relief medication Tab. Acetaminophen
Given. Encouraged the patient to take
rest")
• 6. E - Evaluation: The patient's response
to the interventions (e.g., Patient reports
mild relief of pain after medication
administration. Vital signs stable,").
• 7. .g.").
R - Revision: Adjustments to the care plan
based on evaluation (e.g. Re-evaluate the
need for additional medication if pain
persists or worsens.
Consider additional diagnostic tests if fever
remains and symptoms do not improve.
• Update care plan based on further
assessment and response to treatment.
 [Link] (Problem, Intervention, Evaluation)
• PIE (Problem, Intervention, Evaluation) is a method of
documentation that organizes information into three
categories:
• 1. Problem: Identifies the patient’s issues or conditions.
• 2. Intervention: Describes the care or actions taken to
address the problem.
• 3. Evaluation: Assesses the results of the interventions
and the patient’s progress.
The documentation includes a flow sheet for
assessments and progress notes. Problems are labelled or
numbered, and resolved issues are removed from daily
notes. Continuing problems are documented each day.
[Link] Charting (DAR):
This documentation method organizes notes into
three parts:
• 1. Data: Includes both subjective and objective
information (what the patient says and observable
facts).
• 2. Action: Describes the nursing interventions
taken.
• 3. Response: Records the patient’s reaction to the
interventions.
Focus charting centres on patient concerns, which
could be a sign, symptom, condition, behaviour,
[Link] by Exception (CBE)
• Charting by Exception (CBE) is a documentation system
where only abnormal or significant findings are recorded,
reducing repetitive notes for routine care. It includes:
• 1. Flow sheets for tracking details like vitals, fluid
balance, daily care, patient teaching, and skin condition.
• 2. Standards of nursing care which outline minimum
criteria for care (e.g., checking vitals every hours)Routine
care is marked with a check, saving time on
documentation.
• 3. Bedside flow sheets that allow immediate recording of
data, eliminating extra steps in transferring information
to the permanent record.
 Principles of documentation
• 1. Accuracy 8. Continuity
• 2. Factual 9. Confidentiality
• 3. Clarity 10. Standardized
• 4. Objectivity Language
• 5. Legibility 11. Organization
• 6. Completeness 12. Relevance
• 7. Timeliness 13. Conciseness
14. Accountability
• 15. Consistency
•1. Accuracy:
•Documentation must reflect exact
details. Misleading or incorrect
information can lead to errors in
patient care.

•Example: If a patient’s blood pressure

is 130/85, it should be recorded as it
is, not rounded up to 140/90.
• 2. Factual :
• Record only facts, not assumptions or
conclusions, to ensure the
documentation is clear and credible.

• Example: Instead of writing "Patient

seems anxious," record "Patient
fidgeted in bed, was tapping fingers,
and asked about the procedure."
3. Clarity
Documentation should be
straightforward, without confusing
language or unnecessary details.
•Example: Instead of writing
“patient seems fine,” specify
“patient reports no pain and
appears comfortable.”
4. Objectivity:
•Record only factual information
and observations, not personal
opinions.
•Example: Rather than saying "the
patient was rude," describe the
behaviour: "patient raised voice
and refused treatment."
5. Legibility:
•Documentation must be readable.
This principle is crucial for paper
records, but even electronic
entries should be easy to read.
•Example: Avoid shorthand or
unclear abbreviations that might
confuse other healthcare
providers.
6. Completeness
Ensure all necessary information is
included. Incomplete records may
omit important details about the
patient’s care.
•Example: When documenting
medication, include the name,
dosage, time, and method of
administration.
7. Timeliness:
•Record events as soon as possible
to ensure accuracy and relevancy.
•Example: Document a medication
administration right after giving it,
not hours later.
 8. Continuity:
•Maintain a continuous record of
patient care to provide a complete
picture over time.
•Example: For a patient with high
blood sugar, regularly document
readings and responses to
interventions for tracking.
9. Confidentiality:
•Respect patient privacy by protecting
sensitive information. Only authorized
personnel should access records.
•Example: Avoid discussing patient
information in public spaces or leaving
records open and unattended.
10. Standardized Language:
Use approved abbreviations and
terminology so that all team
members understand the
documentation.
•Example: Instead of using local
jargon, write “BP” for blood pressure
and “q4h” for every 4 hours.
 11. Organization:
Arrange information in a logical
order, making it easy to review. This
includes categorizing notes by date
and time.
•Example: Write notes in
chronological order, starting with
the time the patient was assessed
and ending with the intervention.
12. Relevance:
Document only information relevant
to the patient’s health and
treatment.
•Example: Focus on symptoms
related to the primary condition.
For a diabetic patient, record blood
glucose levels rather than
unrelated information.
13. Conciseness:
Keep documentation brief but
comprehensive, avoiding
unnecessary words.
•Example: Instead of “The patient
mentioned they have pain in their
left arm,” write “Reports pain in left
arm.”
14. Accountability:
•Take responsibility for entries made
by signing or initialling each record.
•Example: Each note should end with
the nurse’s signature, initials, or
identification number.
15. Consistency:
•Use consistent terms and formats in
documentation to maintain
uniformity.
•Example: Always record
medications in the same format
(e.g., name, dosage, method, time).
Characteristics of records:
• 1. Accuracy
• 2. Clarity and Legibility
• 3. Completeness
• 4. Timeliness
• 5. Confidentiality
• 6. Objectivity
• 7. Consistency
• 8. Accessibility
Characteristics of effective reports
• 1. Clarity and Conciseness
• 2. Accuracy
• 3. Relevance
• 4. Objectivity
• 5. Organization and Structure
• 6. Timeliness
• 7. Completeness
• 8. Accessibility
• 9. Professional Tone
 Characteristics of effective
•documentation
1. Accuracy
• 2. Clarity
• 3. Completeness
• 4. Timeliness
• 5. Confidentiality
• 6. Objectivity
• 7. Consistency
• 8. Legibility
• 9. Accessibility
• 10. Accountability
Guidelines for effective
documentation in nursing:
( recording and reporting)
• 1. Record promptly after providing care to
ensure accuracy.
• 2. Use clear, concise, and specific language.
• 3. Document only objective observations and
factual information.
• 4. Avoid vague or ambiguous terms that may
cause confusion.
• 5. Maintain a chronological order for all
entries.
6. Use only approved abbreviations and
terminology.
7. Avoid erasing, overwriting, or using correction
fluid; strike through errors with a single line and
initial.
8. Maintain patient confidentiality by securing
records appropriately.
9. Sign, date, and include your credentials with
each entry.
• 10. Avoid subjective opinions; focus on observed
behaviours.
• 11. Record patient responses to treatments
or interventions.
• 12. Ensure legibility, whether handwritten
or electronic.
• 13. Review entries for accuracy and
completeness before finalizing.
• 14. Document any communication with
other healthcare providers regarding the
patient.
• 15. Follow institutional guidelines and legal
requirements for documentation.