They may be combined or separated into different items: planning refers to realistic and measurable interventions to be implemented (e.g., education, mobility, safety interventions, vital sign frequency) intervention refers to what was done.TensorFlow has APIs available in several languages both for constructing andĮxecuting a TensorFlow graph. Planning and intervention are similar to action. Assessment guides the next steps in terms of planning and interventions.Īction refers to what you did to address the problem (e.g., repositioning the client, providing pain medication). For example, it may include the health problem/issue and nursing diagnosis (e.g., risk for falls, risk for infection). Table 8: Methods used to document the nursing processĪssessment refers to your analysis of the available data. These methods share commonalities see Table 8. SOAPIE (subjective, objective, assessment, plan, intervention, evaluation).SOAP (subjective, objective, assessment, plan) and its derivatives including.APIE (assessment, plan, intervention, evaluation).Several approaches are used for this kind of documentation: This method is also called problem-focused documentation. The nursing process is used to inform documentation in which the 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. She brought him to the emergency, arrived within 30–40 minutes of the fall.” As you can see, this documentation note is both chronological and storied. Client’s mother indicated that he experienced a loss of consciousness for about 20 seconds, was confused when he awoke, and got a headache within 20 minutes. For example: “8-year-old client fell off bike. 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. For example, you would document when the client’s symptoms first started, what they did to treat them, and how they responded to the treatment. Narrative involves chronological documentation that follows a storied format and sequential order. For example, a normal finding may be no signs of infection on an incision: you would only document if the client exhibits signs of infection such as redness, swelling, or discharge. 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. Typically, it involves charting when a finding is not normal.

This method is not commonly used, but some specific units find it helpful. 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.Ĭharting by exception.

In this section, three main documentation methods are presented: charting by exception, narrative, and nursing process. Otherwise, it is usually a matter of personal preference.

Decisions about which method to use may depend on the organization where you work, which sometimes specify certain methods. Several methods of documentation are used to organize a nurse’s notes, sometimes referred to as progress notes.

Transnomino documentation