Narrative charting is a straightforward chronological account of the patient’s status, the nursing interventions performed, and the patient’s response to those interventions that is suitable in any clinical setting. Documentation is usually included in the progress notes and is supplemented by flow sheets. The Joint Commission standards require all health care facilities to set policies on how frequently patients should be assessed. Document patient assessments as often as your institution requires and more frequently when you observe any of the following:

♦ change in the patient’s condition

♦ patient’s response to a treatment or medication

♦ lack of improvement in the patient’s condition

♦ patient’s or family member’s response to teaching.

Document exactly what you hear, observe, inspect, do, or teach. Include as much specific, descriptive information as possible. Always document how your patient responds to care, treatments, and medications and his progress toward the desired outcome. Also include notification to the physician for changes that have occurred. Document this communication, the physician’s response, new orders that are followed, and the patient’s response.

You can organize your notes by using a head-to-toe approach or by referring
to the care plan and documenting the patient’s progress in relation to the plan and any unresolved problems. Regardless of the way you organize your narrative note, be specific and document chronologically, recording exact times.

The POMR system focuses on specific patient problems. Developed by physicians and later adapted by nurses, POMR has five components: the database, problem list, initial plan, progress notes, and discharge summary.

The PIE system organizes information according to patients’ problems. It requires that you keep a daily assessment flow sheet and progress notes. Integrating the care plan into the nurses’ progress notes eliminates the need for a separate care plan and provides a record that has a nursing—rather than medical—focus.

The daily assessment flow sheet includes areas for documenting assessment of major categories, such as respiration or pain, along with routine
care and monitoring. It usually provides spaces to document times treatments were given as well as continued assessments of a specific area such as neurologic checks every hour. Progress notes are organized according to PIE:

FOCUS charting is organized into patient-centered topics, or foci. It encourages you to use assessment data to evaluate these concerns.

Use a progress sheet with columns for the date, time, focus, and progress notes. In the focus column, write each focus as a nursing diagnosis, a sign or symptom, a patient behavior, a special need, an acute change in the patient’s condition, or a significant event. In the progress notes column, organize information using three categories: data (D), action (A), and response (R). In the data category, include subjective and objective information that describes the focus. In the action category, include immediate and future nursing actions based on your assessment of the patient’s condition and any changes to the care plan you deem necessary based on your evaluation. In the response category, describe the patient’s response to nursing or medical care. Using all three categories ensures concise documentation based on the nursing process. All other routine nursing tasks and assessment data can be documented on flow sheets and checklists.