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With charting by exception, the nurse generally starts by working with a standard systems flow sheet (Fig.
Figure AppD-5 shows a graphic flow sheet that indicates multiple areas of routine charting. 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).

The documentation is written as a narrative as the events occurred (ie, narrative chronological charting). For instructional purposes using this example, the NANDA diagnoses are also in bold italics within the charting. Other ways of documenting charting errors are to write recorded in error or mistaken entry and your initials. She handed it out to a few people the other day who wanted to get a head start on the charting assignment.

May i request slides about charting or documentation and recording specific to psychiatric nursing. Most chapters of the November 2014 version of the Guidelines are fully covered with the exception of some parts of Chapter B.

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Author: admin | 25.02.2015 | Category: Can You Make Money Trading Options

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