Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:ANSWER KEY 351
Documentation Method Description/Advantages/Disadvantages
SOURCE-ORIENTED RECORD Each healthcare group keeps data on its own separate form. Notations are entered
chronologically, with most recent entry being nearest the front of the record.
Advantages:Each discipline can easily find and chart pertinent data.
Disadvantages:Data are fragmented, making it difficult to track problems
chronologically with input from different groups of professionals.
PROBLEM-ORIENTED MEDICAL Organized around a patient’s problems; contributes collaboratively to plan
RECORDS of care. SOAP is used to organize data entries in the progress notes.
Advantages:Entire healthcare team works together in identifying a master list of
patient problems and contributes collaboratively to plan of care.
Disadvantages:Some nurses believe that SOAP method focuses too narrowly on
problems and advocates a return to the traditional narrative format.
PIE—PROBLEM, INTERVENTION, Unique in that it does not develop a plan of care; the plan of care is incorporated
EVALUATION into the progress notes in which problems are identified by a number. A complete
assessment is performed and documented at the beginning of each shift.
Advantages:It promotes continuity of care and saves time since there is no
separate plan of care.
Disadvantages:Nurses need to read all the nursing notes to determine problems
and planned interventions before initiating care.
FOCUS CHARTING Its purpose is to bring the focus of care back to the patient and the patient’s
concerns. A focus column is used that incorporates many aspects of a patient and
patient care. The focus may be a patient strength, problem, or need.
Advantages:Holistic emphasis on the patient and patient’s priorities; ease of
charting.
Disadvantages:Some nurses report that DAR categories (Data, Action, Response),
are artificial and not helpful when documenting care.
CHARTING BY EXCEPTION Shorthand documentation method that makes use of well-defined standards of
practice; only significant findings or “exceptions” to these standards are
documented in the narrative notes.
Advantages:Decreased charting time, greater emphasis on significant data, easy
retrieval of significant data, timely bedside charting, standardized assessment,
greater communication, better tracking of important responses and lower costs.
Disadvantages:None noted.
CASE MANAGEMENT MODEL Interdisciplinary documentation tools clearly identify those outcomes that select
groups of patients are expected to achieve on each day of care. Collaborative
pathway is part of a computerized system that integrates the collaborative pathway
and documentation flowsheets designed to match each day’s expected outcomes.
Advantages:Reduced charting time by 40% and increased staff satisfaction with
the amount of paperwork from 0–85%.
Disadvantages:Works best for “typical” patients with few individualized needs.
VARIANCE CHARTING Variances from the plan are documented; for example, when a patient fails to
meet an expected outcome or a planned intervention is not implemented in the
case management model.
Advantages:Decreased charting time; only variances are charted.
Disadvantages:Loss of individualized care.
COMPUTERIZED RECORDS Comprehensive computer systems have revolutionized nursing documentation in
the patient record.
Advantages:The nurse can call up the admission assessment tool and key in the
patient data, develop the plan of care using computerized care plans, add new
data to the patient data base, receive a work list showing treatments, procedures
and medications, and document care immediately.
Disadvantages:Policies should specify what type of patient information can be
retrieved, by whom, and for what purpose (privacy).6.See table below.LWBK696-Ans_p327-424.qxd 9/4/10 3:09 AM Page 351 Aptara Inc.