Different Documentation Methods

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1.  Source-Oriented Records

2.  Problem-Oriented Medical Records (POMR)

3.  Focus Charting

4.  Charting by Exception (CBE)

5.  Case Management Model

Source-Oriented Records

(4)

• Traditional

• Each discipline make notations in separate section

• Info about a specific problem distributed throughout  

• Narrative charting used = no right/wrong order

Pro: Convenient to trace info specific to one's discipline

Con: Info a/b particular problem scattered throughout/ no chronological order; decreased communication among providers, incopmlete picture of pt. care, lack of care coordination

Example:  Papercharts w/ specified tabs

Problem-Oriented Medical Record (POMR)

⁽³⁾

• Data arranged according to problem rather than the source

• Team contributes to problem list, plan of care & progress notes

• Uses SOAP(IER) documentation rather than Narrative charting [Subjective, Objective, Assess, Plan, Intervention, Eval,Revise]

Pros: Encourage collaboration & Easier to track status of each problem

Cons: Less efficient documentation process & Constant vigilance to maintain up-to-date problem list

Focus Charting

(4)

• Focus on client concerns & strengths 

• Progress notes organized in DAR format [Data, Action, Response]  DATA= Assess; ACTION= Plan & Implementation, ASAP/Future/Changes; RESPONSE= Evaluation & describes Clients Response to care

• Provides holistic perspective of patient/ pt. needs

• Nursing process framework for progress notes

Example: D) Guarding abd incision; facial grimace; rates pain 8,

 A) Administered morphine sulfate 4mg IV,

 R) Rates pain 1; states willing to ambulate

Charting by Exception (CBE)

(4)

• Incorporates 1) flow sheets, 2) standards of care, 3) bedside chart forms

• Agencies develop standards of nursing practice

• Only abnormal or significant findings/ Exceptions to standards are recorded in nurse's notes 

• Documentation according to standards involves a check mark

Pros: Eliminates lengthy, repetitive notes & Obvious changes n condition evident

Cons: Automatically assumed that nurse assessed for abnormal conflicts w/ common mindset "not charted, not done"

Case Management Model

(5)

• Quality, cost effective care delivered within an est. length of stay

Critical Pathways

identify outcomes that certain groups of pts are expected to acheive on each day of care, along w/ the interventions necessary for each day

Variance

What does a nurse do when a variance occurs?

A goal that is not met; a deviation to what is planned on the critical pathway or unexpected occurrences that affect the planned care or the client's responses to care.

When a variance occurs...

Nurse writes note documenting the unexpected event, the cause, and actions taken to correct the situation or justify the actions taken