L2: Types of Documentation

Question 1

The traditional method for recording nursing care provided. It is a story-like format to document information specific to client conditions and nursing care.

Answer 1

NARRATIVE DOCUMENTATION

Question 2

This type of charting focuses on the client’s problems and utilizes a structured approach to charting progress notes.

Answer 2

PROBLEM-ORIENTED (SOAP)

Question 3

• Numbered or labelled according to the client’s problems.
• Resolved problems are dropped from daily documentation after the RN’s review.
• Continuing problems are documented daily.

Answer 3

PROBLEM-ORIENTED (PIE)

Question 4

Consists of notes that include data, both subjective and objective; action or nursing interventions; and response of the client.

Answer 4

FOCUS CHARTING (FDAR)

Question 5

• Developed in response to problem-oriented charting as a means to free nurses from having to do extensive time-consuming charting.
• Charting is done intermittently if there are unexpected findings or events.

Answer 5

CHARTING BY EXCEPTION (CBE)