NURSING DOCUMENTATIONS

Includes types of documents, do's and don't, and sample charting

Parental fluid sheet

Used to document the IV fluid of the client

vital signs sheet

document V.S of the client

nurses notes

documents all intervention

graphic chart

use after you did vital signs

doctors order

provide specific medical treatment, interventions, medications, or test

medicine record

used to document all drug administered to the client

prescription pad

used to write prescription for medications or medical treatment

going home instruction form

for client who already allowed to go home

fluid intake and output

assess and manage patients over all physiological well-being

kordex

used for indorsement

subjective

sample charting- SOAPIE:
This section includes information provided by the patient, such as their symptoms, feelings, and concerns.

objective

sample charting- SOAPIE:
This section includes measurable data obtained by the healthcare provider during the encounter, such as vital signs, physical examination findings, and test results.

assessment

sample charting- SOAPIE:
This section involves the healthcare provider's assessment or diagnosis based on the subjective and objective information.

planning

sample charting- SOAPIE:
This section outlines the treatment plan or course of action based on the assessment.

interventions

sample charting- SOAPIE:
Actions taken by the healthcare provider to address the patient's condition.

evaluation

sample charting- SOAPIE:
Assessment of the effectiveness of interventions.

focus

sample charting-FDAR:
Wound care for a patient with a Stage II pressure ulcer on the sacral area.

data

sample charting-FDAR:
Patient's wound assessed: Stage II pressure ulcer observed on the sacral area, measuring 3 cm x 3 cm with pink wound bed, minimal serosanguinous drainage, and intact surrounding skin.

• Patient reports pain at the wound site as 4/10 on a numeric rating scale.

• Vital signs stable.

• Wound care history: Last dressing change performed 24 hours ago with application of hydrocolloid dressing.

action

sample charting-FDAR:
Nursing intervention performed, plans to be performed, protocols & procedure initiated.
EX:
Cleanse wound using normal saline solution and gentle irrigation to remove debris and excess exudate.

reaction/response

sample charting-FDAR:
description of an individual’s response to medical & nursing care.
EX:
The patient reports pain at the wound site reduced to 2/10 on a numeric rating scale.