Methods of Documentation – Documentation in Nursing: 1st Canadian edition

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• 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

• Narrative

• 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.

• nursing process

• 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