Documentation

Cherybaby · Jul 10, 2009

I did some research on the AllNurses website and found these threads. They may be helpful for you! Also posting some info on the SOAP way of doing nursing notes. Hope these help! Good luck!

https://allnurses.com/general-nursing-discussion/examples-good-nursing-107417.html

https://allnurses.com/nursing-student-assistance/nursing-documentation-168921.html

S - O - A - P

1. SUBJECTIVE — The initial portion of the SOAP note format consists of subjective observations. These are symptoms the patient verbally expresses or as stated by a significant other. These subjective observations include the patient's descriptions of pain or discomfort, the presence of nausea or dizziness, when the problem first started, and a multitude of other descriptions of dysfunction, discomfort, or illness the patient describes.

2. OBJECTIVE — The next part of the format is the objective observation. These objective observations include symptoms that can actually be measured, seen, heard, touched, felt, or smelled. Included in objective observations are vital signs such as temperature, pulse, respiration, skin color, swelling and the results of diagnostic tests.

3. ASSESSMENT — Assessment follows the objective observations. Assessment is the diagnosis of the patient's condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities.

4. PLAN — The last part of the SOAP note is the health care provider's plan. The plan may include laboratory and/or radiological tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., home care, bed rest, short-term, long-term disability, days excused from work, admission to hospital), patient directions, and follow-up directions for the patient.

Daytonite, BSN, RN · Jul 11, 2009

see this sticky on the student forums. it links you into several examples of correct charting, has discussions about how to chart as well as a link to a website with exercises on how to chart correctly:

https://allnurses.com/nursing-student-assistance/nursing-documentation-168921.html - nursing documentation

gettingupthere · Jul 15, 2009

If you have patients on Med A, you need to be very specific in your documentation. For instance, should this resident have a hip fx, then you need to document on pain level, meds given and effectiveness. How they transfer, do any self cares, self feed, coninence, how they toilet, how much assistance is needed. Identify the reason that they are in the facility and document anything pertinent to their stay.

Good luck! It will come easier as time goes by.

sasha2lady · Jul 21, 2009

I also work in LTC ...my charting ranges from med a....medicaid...acute changes and if someone has a fall/incident we chart for 3 days on that issue....if someone starts on an antibiotic..we chart for 3 days what their temp is or if any s/s of a reaction...depending on what the atb is for....UTI, URI...etc. when i chart on my med a pts....for example...if i have one who is there for a cva and has a peg tube...i chart on their orientation, how the tube flushes and allows the feeding to go thru plus how the site itself looks....I chart whether or not that pt is confused and how ....like...if they dont know where they are or who anyone is....i chart if they are continent or not...etc....on our medicaid pts...we have to chart q s x 7 days....we chart if they walk and if so do they use a rw.....can they propel in a w/c....examples of stm and ltm loss...(ex...cannot name book, apple, chair after 5 mins, or can name year but not month...etc)...whether or not they are continent, if they feed or dress themselves or at least try to help with adls...etc....it all boils down to money ....the more we chart on that they need...the more money medicare or medicaid pays....b/c it increases their rug scores....but thats a whole other topic all together...this is just how it works at my facility...but its pretty general i guess. I also chart on anyone who has behavior problems....like if they pace or get agitated in the pm....if they have inc confusion or wandering...b/c if that charting isnt there the psych person comes in and orders all kinds of stupid stuff.......it will come to you better as time goes on......it took me a long time to get it b/c i didnt do alot of that kind of charting in school....we used flow sheets mostly so i was LOST when i actually had to do the real deal. good luck :)

NurseCubanitaRN2b, BSN, RN · Jul 24, 2009

It looks like a lot of advise has been given regarding charting. Nurses notes was my pet peeve in nursing school. I hated reading incomplete and vague documentations by the RNs in the hospital. You can keep it short and to the point just make sure that it's pertinant to the patients care. It can be though as the above poster did mention, just make sure it's pertinant to their care. I would read nurses notes that would mention that the family was in the room, or that lab was with the patient drawing blood. Our clinical instructor advised not to chart that family was in the room, unless they were doing something specific like assisting them with their ADLs or something like that. The fact that lab was in their room is pertinent to their care but lab charts that they were in there. This facilities had locators so therefore it was showing that lab was locating in the patients room and it goes straight to the lab.

What I'd like to know is how do nurses handle a situation where you're updating a doctor on the phone regarding a patients condition that needs some sort of order for a medication that you can't seem to get an order for. For example I was doing my clinical rotation and the patient didn't have ANY ORDERS FOR PAIN MEDICATIONS and he had a hip fx and just had surgery. The nurse kept calling the doctor and she would chart that she called the doctor but that's it. She didn't give any details. What I turned in to my clinical instructor that day said "Dr. So & So notified regarding pt So & So requesting pain medication for post surgery, no orders received" I didn't chart that there were no pain medications ordered because it's in the electronic MAR and when you print it out it's there. I guess the doctor forgot to check them off in the chart. The pain medications are there, but he didn't check the boxes. He was contacted several times but no phone call returned until the 4th time, then it was returned, but no new orders were received. Since I didn't talk to the doctor myself I can't comment on what he told the nurse. But look the nurse didn't document what was said by the doctor or why he hadn't given any orders. So incomplete charting will only open up a can of worms for a law suit if something happens.

Daytonite, BSN, RN · Jul 25, 2009

You always have an obligation to notify a physician if there is a change in a patient's condition. I always charted what I said when I called a doctor. For example. . .

Dr. XXX phoned and notified that patient was complaining of abdominal pain and asking for something stronger than Tylenol. Discussed Tylenol administration per MAR and a stronger pain medication was requested. No order given. Spoke with patient and told her that the doctor was notified and doesn't want to order something stronger at this time. Repositioned in bed to a position of comfort.

If the patient gets worse you keep documenting. You notify the supervisor or you manager and chart it. . .

Dr. XXX notified that patient is now screaming and yelling as well as grabbing their abdomen in pain. Dr. notified that the patient is demanding a "shot" for pain, but no order given. Told that the patient is noisy and causing a disruption to the rest of the patients on the unit and request that something be done to quiet the patient. "You're the nurse. You do something." Nursing supervisor notified. Patient's family notified.

Supervisor on unit. Supervisor is calling Dr. XXX.

When a doctor fails to act, it is a problem that has to be passed up the ranks through your supervision and management.

TheCommuter, BSN, RN · Jul 29, 2009

Here's a basic documentation tool that is easy for me to remember. It is also applicable to long term care as well as acute care settings.

It is called DAO (Data - Action - Outcome).

"D" is for documenting the objective and subjective data: 98.6, 74, 18, 120/80. Skin warm & dry to touch, dressing CDI, alert & cooperative during exam, no s/s of acute distress noted, pt. states, "I have a headache."

"A" is for documenting the actions or interventions you took: Administered Tylenol 500mg, 2 caplets by mouth per order. Offered oral fluids for hydration. Taught pt. to report any pain or discomfort in a prompt manner to nursing staff.

"O" is for documenting the outcome or result: 60 minutes elapsed and pt. reports pain level of zero using numeric scale. Pt. states, "My headache is gone." Pt. observed accepting sips or water and watching television.