Nurse Charting2

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In Depth Tutorials and Information
Examples of Documentation: Forms and Formats

(Nursing)
The following examples demonstrate various forms and formats of documentation. Computerized templates of
forms or hard copy pen-and-paper preprinted forms can be used, depending on the individual facility needs, resources,
and requirements.
Documentation is an integrated component of the process of developing a nursing care plan that is initiated by the
appropriate nursing personnel. The initial admission assessment is commonly the responsibility of an RN, but may be
delegated to the LPN/LVN and co-signed by an RN. Nursing diagnoses (NANDAs) are integral parts of the nursing
process and need to be reflected in your facilitys documentation and record-keeping formats. The basic nursing
process consists of the assessment, identification of NANDAs, plans with specific goals, interventions or
implementations, and the evaluation of each plan or goal. (Refer to Unit 6.)
For demonstration purposes, the abbreviated medical history below is appropriate for all examples (Figs. AppD 1-
5). The NANDA diagnoses are developed from this medical history and from an initial comprehensive admission
nursing assessment, which is not provided here. A fourth problem is identified by the nurse and is used for examples
of charting formats.
Abbreviated Medical History

Ms. G. H. is a 74-year-old female who was admitted to an acute-care facility from a long-term care facility. Her
history includes a cerebrovascular accident 2 years ago, resulting in weakness of the left leg. She was admitted to the
acute care facility 2 days ago with a diagnosis of left lower lobe pneumonia.
NANDA Diagnoses
1. Gas exchange impaired related to pneumonia as manifested by LLL crackles, admission temperature of 101 F,
and pulse oximetry of 89% without supplemental O2
2. Acute confusion related to pneumonia and change in environmental surroundings as manifested by oxygen
saturation of 89% and disorientation to time and place
3. At risk for impaired tissue integrity related to bed rest and lack of physical mobility
EXAMPLES OF NARRATIVE-CHRONOLOGICAL NURSES PROGRESS NOTES
In this example, a head-to-toe assessment by body system is used. The documentation is written as a narrative as the
events occurred (ie, narrative chronological charting). Notice how the numbered NANDAs, from the abbreviated
medical history above, are integrated into the assessment.
Figure AppD-1A addresses the three major NANDA diagnoses, which are numbered in the NANDA Diagnosis
column. For instructional purposes using this example, the NANDA diagnoses are also in bold italics within the
charting.
For our example of charting, the nurse completes an initial shift assessment. At the time of the collection of data, the
nurse also discovers significant abnormal findings related to nausea, abdominal distention, and pain. A fourth
NANDA is then developed relating to the newest priority (Fig. AppD-1B).
PROBLEM AREA (FOCUS) CHARTING
SOAP (Subjective, Objective, Analysis, Plan)
Each NANDA diagnosis would be documented with its own SOAP format. For this example, the focus will be on the
new problem, NANDA #4.
APIE (Assessment, Problem, Implementation, Evaluation)
Each NANDA diagnosis would be addressed separately using the APIE format based upon the nursing assessment,
the care plan, and the NANDAs. Here, the format of APIE is updated with the newest finding.
EXAMPLES OF SYSTEMS FLOW SHEET AND CHARTING BY EXCEPTION
With charting by exception, the nurse generally starts by working with a standard systems flow sheet (Fig. AppD-4A),
which indicates most normal findings according to body system (neurologic, cardiovascular, and so forth) or other
organized, preprinted format.
EXAMPLE OF GRAPHIC FLOW SHEET

Figure AppD-5 shows a graphic flow sheet that indicates multiple areas of routine charting.
FIGURE IA Example of narrative-chronological nurses progress notes.
Nursing Diagnosis, continued and updated from original admission assessment:
4. Gastrointestinal tissue perfusion ineffective related to mechanical blockage of peristalsis as manifested by

hyperactive bowel sounds RUQ, absent bowel sounds in remaining quadrants, and acute, severe abdominal pain and
nausea. M Kowalski, RN
*Note to student: An error in charting can be addressed by drawing a single line through the error and writing
ERROR and your initials. Put this in parentheses. Other ways of documenting charting errors are to write recorded in
error or mistaken entry and your initials.
FIGURE IB The nurse has identified a new problem and added it to the nursing care plan.
FIGURE 2 Example of problem area (focus) charting: SOAP (subjective, objective, analysis, plan).
FIGURE 3 Example of problem area (focus) charting: APIE (assessment, problem, implementation,
evaluation).
FIGURE 4A Systems flow sheet.
FIGURE 4B Charting by exception.

FIGURE 5 Graphic flow sheet.
Next post: Glossary (Nursing) Part 1

Previous post: Medical Terminology: Prefixes,Roots, and Suffixes Commonly Used in Medical Terms (Nursing) Part
2
Related Links
o Nursing
The Origins of Nursing (The Nature of Nursing) Part 1
The Origins of Nursing (The Nature of Nursing) Part 2
Beginning Your Nursing Career (The Nature of Nursing) Part 1

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what-when-how

In Depth Tutorials and Information

Examples of Documentation: Forms and Formats

Abbreviated Medical History

EXAMPLES OF NARRATIVE-CHRONOLOGICAL NURSES PROGRESS NOTES

PROBLEM AREA (FOCUS) CHARTING

SOAP (Subjective, Objective, Analysis, Plan)

EXAMPLES OF SYSTEMS FLOW SHEET AND CHARTING BY EXCEPTION

EXAMPLE OF GRAPHIC FLOW SHEET

FIGURE IA Example of narrative-chronological nurses progress notes.

Nursing Diagnosis, continued and updated from original admission assessment:

4. Gastrointestinal tissue perfusion ineffective related to mechanical blockage of peristalsis as manifested by

FIGURE 4B Charting by exception.

Next post: Glossary (Nursing) Part 1

The Origins of Nursing (The Nature of Nursing) Part 1

The Origins of Nursing (The Nature of Nursing) Part 2

Beginning Your Nursing Career (The Nature of Nursing) Part 1

Beginning Your Nursing Career (The Nature of Nursing) Part 2

Beginning Your Nursing Career (The Nature of Nursing) Part 3

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