Another method that is sometimes used to inform documentation is SBAR (Situation, Background, Assessment, and Recommendation), as discussed in a previous chapter, but this was typically designed to inform verbal communication
Charting by exception
charting when a finding is not normal
A specific setting will provide a list of normal ranges or normal activities, and you will only document a note if the client’s activities or your assessment findings are outside of the norms
chronological documentation that follows a storied format and sequential order
A storied format involves attending to ‘what,’ ‘when,’ ‘who,’ and ‘how’ – what happened, when did it happen, who was involved, how the client responded, etc.
nurse focuses on the client’s issue/concern/problem,
followed by the plan and action to address the issue, and an evaluation of how the client responded
DAR (data, action, response) APIE (assessment, plan, intervention, evaluation) SOAP (subjective, objective, assessment, plan) and its derivatives including SOAPIE (subjective, objective, assessment, plan, intervention, evaluation).
Assessment refers to your analysis of the available data
Action refers to what you did to address the problem
Response and evaluation refer to the outcome of the intervention
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