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.

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