Many healthcare workers, particularly in nursing, are familiar with charting and documenting are essential components of any healthcare job. Although there are multiple kinds of documents and charting available, health professionals often use some common charting patterns, particularly those in the nursing field. Comprehensive charting systems help healthcare communicate and share, make sure the quality of care delivery does not experience when shifts alter or while being moved across patient care, aid in the creation of a record of invoicing services for insurance providers or other funders, can preserve nurses or employees in the event of a claim, and allow you to demonstrate the contributions as a nursing professional (“Nurse Charting 101 | Berxi™”, 2021). Being that nursing is my preferred profession, it is critical for other future nurses and me to fully grasp the charting methods that will be used in order for us to be successful. In this article, I will explain the purposes of both charts and potential improvements that might be made to either one.
PIE charts were initially created in 1984 by nurses in North Carolina to make documentation more popular in the medical community. Many healthcare professionals, particularly nurses, use this charting style. Because nursing is my preferred profession, it is critical that I fully comprehend this charting style and its implications. It is an abbreviation that represents Problem(P), Intervention (I), and Evaluation(E) in the pie chart (E). The development of PIE charts assisted in abolishing the usage of the more conventional nursing care plan in certain situations. The PIE charting technique consists of the following steps: P, determine what is wrong with the patient by making an evaluation and then defining the issue, I, describe what was performed in order to relieve the condition, and E, report how the treatment functioned. A separate sheet is used in the patient chart to record the findings, with each worry being assigned a number by the nurse. Every time caregivers refer to that particular issue in the patient’s record, and they refer to it by the number given to them. The whole process is problem-oriented, comparable to SOAP, and it includes a lot of the same ground as SOAP charting, but it is a bit more straightforward to implement and maintain. However, simpler is not always preferable. In contrast to more comprehensive recording methods, PIE charting does not establish a primary care plan. Consequently, different nurses may approach the issue in a variety of ways, possibly resulting in inconsistent patient care.
SOAP charts are only one of the numerous charting methods that nurses across the board utilize. The term SOAP means subjective(S), objective(O), assessment(A), and plan. IER is optional, but all nurses are free to include it if they choose. In certain instances, nurses may choose to turn it SOAPIER, which would simply include Intervention (I), evaluation(E), and revision(R). It is not essential to include the IER, but all nurses are invited to do so. Typically, this charting method is used to assist nurses through the process of recording a diagnosis or other medical condition. This SOAP method is used in the following ways: Subjective will cover the patient’s history, including all medical records or the patient’s current diagnosis progression, or any information, questions, and issues that are relevant to the issue (“Nurse Charting 101 | Berxi™”, 2021). The objective will contain the patient’s history, including all medical records or the patient’s current symptom progression. The objective section of SOAP is also where the caregiver will enter the patient’s data, including vital signs, lab results, examinations, and observations made during the patient’s visit. Assessment is likely to be the part in which the main medical concern is explained, what the issue might be, and what information should be provided to support the information provided in sections S and O are all discussed in detail. Following the diagnosis has been provided, the last part will begin. It will include the treatment plan and address any changes to the patient’s treatment plan, including any medications, self-care guidelines, follow-ups, or recommendations given to the patient. According to Hudson, even though SOAP charts are extensively utilized in health care settings, they have become less common with time. This is due, at least in part, to the time it would take to complete. In addition, this approach may result in a large amount of the same information being recorded for each issue, which is especially true if the problems overlap.
Because they both cover the same concept and general information for patients at each visit, a nurse may successfully utilize either one with a positive result in most cases; nevertheless, they will both be necessary for all healthcare professionals in the future. Documenting in the healthcare sector allows all medical staff team members to communicate efficiently, guarantee patient safety, and provide a source for invoicing agencies to know what procedures and treatments were performed. It can also protect caregivers and employees in the event of a claim and documentation of the task each caregiver or health professional has performed, making such style charting structures crucial and precious in today’s healthcare sector.
The patient reports left arm discomfort and leg weakness, which worsens as the patient climbs the stairs. The discomfort is agonizing and worst at night, although it gets better when the leg is elevated.
- Respiration: 16 bpm
- Temperature: 98.5
- Weight: 165 kg
- Pulse Oximetry: 97%
- Pulse: 60 bpm
- Blood Pressure: 165/85
- Rate pain 5 out of 10
- Height: 182 cm
- Hypertension, bilateral edema legs, and ankles, Heart Disease, Diabetes
Bilateral edema ankles and both legs, Diabetes, Hypertension and Heart Disease
- Hydrochlorothiazide, 25 mg tablet, 1 per day in the am.
- Elevate legs for 1 hour 4 times a day
- Return for follow-up in two weeks
- Wear support stockings till next appointment
Patient Elizabeth Johnson (date of birth 15th August 1995) came to the hospital for a checkup. She reported, she is having pain in her left arm and weakness in the body. She also said that she is feeling aches in her legs which increase while she walks. She also reported nausea, chills, anxiety, and temperature issues. She said that her stomach was also upset and also faced gastric issues. Issues of gastric increase in the night while she lay on beds for sleep. Moreover, she is facing headache problem, and her body starts shivering during headache, and there is also an issue of bowel movement.
She is facing different issues. First of all, the patient is suffering from hypertension as she feels anxiety, because of which she is having chills and nausea. Also, gastric problems are because of her anxiety and overthinking.
So, for this purpose, she will take 0.25 mg Alprazolam (half pill) at night. 1 Omeprazole 20 mg will be taken after eating food at night. Omeprazole is prescribed for the gastric issue, and Alprazolam is given for the anxiety issues. One cholecalciferol after ten days is required to eat. 1 Panadol (500mg) should be taken at 8 am, 2 pm, and 8 pm.
The patient had not faced headaches, chills, nausea, anxiety, depression anymore. The problem of gastric and stomach issues are also not occurred again. Her body is recovering by using vitamin D3, which will help in pain relief.
Nurse Charting 101 | Berxi™. Berxi.com. (2021). Retrieved 4 October 2021, from https://www.berxi.com/resources/articles/nurse-charting-101/#the-importance-of-documentation-in-nursing.