Examples & Functions of Nursing Documentation
“If You Didn’t Write It Down, You Didn’t Do It”
This old nursing adage, applicable to all nursing documentation examples, has to be one of the oldest and most frequently used teaching tools in nursing education, yet it remains as valid today as it was a century ago. According to an article by Nikki Campos, “The Legalities of Nursing Documentation,” published on Lippincott’s online NursingCenter.com, “the objective of any state’s nursing practice, act as it pertains to documentation is the same across the country: to provide a clear and accurate picture of the patient while under the care of the healthcare team.” Communication to other healthcare providers is the first function of nursing documentation, always with an eye toward the goal of meeting and documenting standards in patient care.
Examples of Nursing Documentation
Even as nursing documentation transitions from written records to Electronic Health Records (EHRs), the types of routine nursing documentation remain the same. The most common types of nursing documentation include the following:
Nursing Progress Notes
Nursing progress notes are one of the most frequent and time consuming of nursing documentation tasks. In addition to the historical narrative notes, several other systems have been devised over the years to save time, improve documentation and standardized nursing notes. Types of progress note documentation systems include:
Narrative Nursing Notes
- Inconsistent quality demonstrated
- Used in typical “source records” hospital charts with information organized by information sources
Problem-Oriented Nursing Notes
- Also referred to as Problem-Oriented Medical Records or “POMR”
- Data is ideally organized by diagnosis
- All members of the healthcare team utilize the progress note section
- POMR notes typically use one of a number of organizational styles of writing progress notes:
- SOAP or SOAPIE Notes
- (S) Patient’s subjective complaint
- (O) Objective findings
- (A) Assessment findings
- (P) Nursing or medical plan
- (I) Intervention
- (E) Evaluation of effectiveness
- PIE Charting
- (P) The problem as identified
- (I) A planned intervention
- (E) An evaluation of the efficacy of the intervention
- (D) Objective data documenting problem
- (A) Action or intervention planned
- (R) Patient response to intervention conducted
- DAR Focus Charting
- SOAP or SOAPIE Notes
Charting By Exception Nursing Notes
- Used primarily in long-term care facilities
- Decreases burden of frequent documentation of a primarily unchanging condition
- Saves time and decreases the size of medical record
- Assumes all standards are met unless otherwise noted
- Exceptions require documentation
Nursing Admission Assessment
Nursing admission assessments are multipage forms that document a patient’s current condition, previous medical history, allergies, prescription drugs and primary complaint at the time of his or her admission to the hospital. The information is collected through an interview conducted with the patient and/or family and via a careful physical examination by the admitting nurse. The information and data garnered during a nursing admission assessment forms the basis of the nursing care plan. Some facilities have different admission assessments utilized for the different types of care provided. For instance, a patient may require an Emergency Department (ED) Nursing Admission Assessment followed by an Intensive Care Unit (ICU) Admission Assessment completed upon transfer. When the patient improves enough to be transferred to the general medical population, he or she will often have another nursing admission assessment completed to reflect the new goals for the patient’s improved condition.
Nursing Care Plans
Nursing care plans are the organized means by which patient problems (nursing diagnoses) are identified, and nursing interventions prescribed to address the patient’s physical, mental, social, psychological or educational needs. Characteristics of these documents include:
- Standardized plans of care based upon disease or nursing diagnosis
- Modification of the care plans based upon the patient’s individual needs
- Promotes improved and standardized means of patient care
- Ensures treatment based on the same minimum level of knowledge among all healthcare providers
Graphic sheets refer to charts and graph that aid in documenting objective physical measurements required during patient care. These include:
- Vital Signs Graphics
- Allows graphing of patient pulse, blood pressure, temperature and respiratory rate on a single multidimensional graph
- Provides an area for recording patient weight
- Intake/Output Record (I & O)
- Allows staff to record patient fluid intake by mouth or intravenously to be totaled at the end of each shift and each day
- Allows staff to record patient fluid output by urinary catheter, nasogastric suction or urination into measured containers to be totaled at the end of each shift and each day
- The resulting sum allows staff to document fluid retention or hypovolemia
Medication Administration Records (MARs)
Whether hand-written, partially computerized or totally computerized, medical administration records (MARs) document what medications are prescribed to each patient, the dosage, the administration route, and the administration schedule. Each nurse “initials” or indicates administration of each medication as provided to his or her assigned patients. MARs are reviewed prior to each nursing shift to ensure that any medication changes have been properly recorded.
Get Matched to Online Programs In A Few Clicks!
Ranked among the Best Online Bachelor's Programs in 2015 by U.S. News and World Report.
- BS in Business Administration
- MS in Accounting - Audit Specialization
- AAS in Criminal Justice
- And more...
Argosy University offers doctoral, master's, and bachelor's degree programs to students through its eight colleges.
- Business Administration (BS)
- Curriculum and Instruction (EdD)
- Liberal Arts (BA)
- And more...
100% Online & No Standardized Testing
- Doctor of Education: Community Care & Counseling: Marriage & Family
- Doctor of Ministry: Evangelism & Church Planting
- M.Div: Homiletics
- And more...
Earn your degree or diploma on your schedule and succeed at Ashworth College.
- Payroll Clerk
- Private Investigation
- High School
- And more...
Aviation Institute of Maintenance schools are distinguished institutes committed to the education and personal enrichment of each student interested in the Aviation Industry.
- Aviation Maintenance Technician
- Aviation Maintenance Technical Engineer
Study for your graduate education with University of Illinois at Chicago.
- Master of Science in Health Informatics
Whether you’re looking to advance in your current role or transition into a new one, UND’s online Master of Science in Cyber Security is a great choice. Our master’s program allows you to complete general coursework or specialize in one of three areas that can prepare you for leadership in the growing field of cyber security.
Choose from four tracks:
- Autonomous Systems Cyber Security
- Data Security
- Cyber Security and Behavior
- General Cyber Security
100% Online. Transfer credits accepted. 20 months to complete. No prior work or education experience required.
About University of North Dakota:
UND is ranked alongside Stanford, Harvard and Massachusetts Institute of Technology (MIT) among the Top 25 Most Innovative Schools by US News and World Report. Our groundbreaking discoveries, economic impact and notable alumni are a testament to our belief that results matter. Our online master’s in cyber security program is offered through the UND College of Engineering & Mines (CEM) — one of the most well-respected engineering schools in the upper Midwest. That means when it comes to quality, you can be confident in UND.
- Master of Science in Cyber Security
Ohio University has offered distance learning educational opportunities for more than 100 years.
- Master of Business Analytics
- Master of Health Administration
You can receive a top-notch education in a flexible environment. Learn more about the Villanova online learning experience and the difference that sets us apart by further exploring our online programs.
- Online Master of Laws in Taxation
- Online Master of Science in Analytics
- Online Master of Business Administration
- And more...
Advance your career with an online degree from California InterContinental University.
- Bachelor of Engineering Information Technology Emphasis in Network and Systems Security (BEITNSS)
- Bachelor of Engineering Information Technology in Project Management (BEITPM)
- Master of Business Administration in Healthcare Management and Leadership (MBAHCML)
- And more...
The Online MSN – FNP Program From Simmons College
- MSN - Family Nurse Practitioner
- RN to MSN - Family Nurse Practitioner
At the University of Nevada, Reno, we teach public health practitioners how to look beyond physical conditions and consider environmental, economic and sociological factors that impact individual and community health, happiness and well-being.
The online Master of Public Health in Public Health Practice is designed to prepare you for employment in nearly any area of the public health field.
- Online Master of Public Health (MPH)