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Different Types of Nursing 
Documentation Methods 
There are two categories of documentation methods in nursing such as 
documentation by inclusion and documentation by exception. In the former, nurse 
practitioners make note of all assessment findings, nursing interventions and client 
outcomes on an ongoing, regular basis. In the latter, they make note of negative 
findings and this documentation is completed when review findings, nursing 
interventions or client outcomes show a variation from the established assessment 
norms / standards of care prevailing in a particular practice setting. The common 
documentation methods in these categories are focus charting, SOAP charting and 
narrative charting. Nurse practitioners can select any of these methods, but ensure 
that the selected method reflects client care needs and the context of practice. 
Focus Charting 
This documentation method focuses on particular client concerns/behaviors, a 
change in the client’s condition/behavior, or a significant event in the client’s 
treatment determined during the assessment. In the documentation, three columns 
are utilized for focus charting or F-DAR charting such as:
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 Date and Hour – The relevant date and time are added here (for example, 
20/10/2014, 7.30pm) 
 Focus – This represents focus of care, which may be a current concern or 
behavior of the client, a change in a client’s condition or behavior or a significant 
event in the client’s treatment (for example: pain, hyperthermia) 
 Progress Notes – These are organized into Data, Action and Response, which is 
referred to as DAR format. 
 Data (D) – This is the assessment phase of the nursing process which 
includes subjective and/or objective information that supports the focus 
stated on the chart or describes the client status during the time of a 
significant event or intervention (for example, if the stated focus is pain, then 
the practitioner should note down what type of pain, the location of pain and 
how patient feels under Data). 
 Action (A) – This represents the planning and implementation phase of the 
nursing process where completed or planned nursing interventions based on 
the assessment of the client’s status is described (for example, medicines, 
advices, exercises). Changes to the plan of care are also included in this 
section. 
 Response (R) – This section is the evaluation phase of the nursing process 
in which the impact of the interventions on client outcomes is described (for 
example, if pain is the focus, then the observation whether pain is relieved or 
not is mentioned under Response) 
Flow sheets and checklists are often used as an adjunct in order to document 
routine and ongoing assessments as well as observations including vital signs, 
personal care, etc. It is not required to repeat the information noted down on flow 
sheets in the progress notes.
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SOAP Charting 
SOAP charting uses a problem-oriented approach to documentation in which nurses 
first identify and list out patients’ problems and documentation is done on the basis 
of identified problems. This type of documentation is typically organized in the 
following manner: 
 Subjective (S) – Nurses document how the patient actually feels in this 
section such as symptoms, patients’ complaints, medication side effects and 
so on. The patient’s own words are used as much as possible. 
 Objective (O) – This section represents objective data including results of 
the physical exam, vital signs, lab results and studies. 
 Assessment (A) – In this section, the patient’s status such as the diagnosis, 
prognosis, treatment, and side effects is documented along with the patient 
profile (age, sex, occupation, martial status and significant characteristics) 
 Plan (P) – The medication strategy, planned tests and discharge plans are 
documented in this section. The section also discusses whether the plan stays 
the same or whether any changes are needed. 
Flow sheets and checklists are used frequently as an adjunct along with SOAP 
charting. 
Narrative Charting 
In this method, the patient’s status, nursing interventions and patients’ responses to 
those interventions are documented in chronological order covering a specific time 
frame. This information is typically included in progress notes and is supplemented 
by other tools including flow charts and checklists. It is required to document the 
patient assessments whenever the institution demands and more frequently when 
the following things are observed.
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 Change in the patient's condition 
 Patient’s response to a particular treatment or medication 
 No improvement in the patient's condition 
 Patient’s or family member's response to teaching 
It is required to document what you hear, observe, inspect, do or teach along with 
specific descriptive information as much as possible. You should also include 
notification to the physicians if changes occurred. The physician’s response, new 
orders that need to be followed and the patient’s response should be documented as 
well. You can use a head-to-toe approach to organize your notes or you can refer to 
the care plan and document the patient’ progress with respect to the plan and any 
unresolved problems. 
Whichever documentation method you select, make sure that it reflects client care 
needs and the context of practice. Certain institutions may combine elements of 
different documentation methods and formats. There should be a standard 
documentation procedure within the healthcare institution and if the institution 
changes its method or format, it should be done within the context of appropriate 
planning, involvement of nurses and their education. Accurate and standard 
documentation improves the communication between physicians and nurses, 
promotes good nursing care and helps to meet professional and legal standards. 
Contact 
MTS Transcription Services 
8596 E. 101st Street, Suite H 
Tulsa, OK 74133 
Main: (800) 670 2809 
Fax: (877) 835-5442

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Different Types of Nursing Documentation Methods

  • 1. www.medicaltranscriptionservicecompany.com Different Types of Nursing Documentation Methods There are two categories of documentation methods in nursing such as documentation by inclusion and documentation by exception. In the former, nurse practitioners make note of all assessment findings, nursing interventions and client outcomes on an ongoing, regular basis. In the latter, they make note of negative findings and this documentation is completed when review findings, nursing interventions or client outcomes show a variation from the established assessment norms / standards of care prevailing in a particular practice setting. The common documentation methods in these categories are focus charting, SOAP charting and narrative charting. Nurse practitioners can select any of these methods, but ensure that the selected method reflects client care needs and the context of practice. Focus Charting This documentation method focuses on particular client concerns/behaviors, a change in the client’s condition/behavior, or a significant event in the client’s treatment determined during the assessment. In the documentation, three columns are utilized for focus charting or F-DAR charting such as:
  • 2. www.medicaltranscriptionservicecompany.com  Date and Hour – The relevant date and time are added here (for example, 20/10/2014, 7.30pm)  Focus – This represents focus of care, which may be a current concern or behavior of the client, a change in a client’s condition or behavior or a significant event in the client’s treatment (for example: pain, hyperthermia)  Progress Notes – These are organized into Data, Action and Response, which is referred to as DAR format.  Data (D) – This is the assessment phase of the nursing process which includes subjective and/or objective information that supports the focus stated on the chart or describes the client status during the time of a significant event or intervention (for example, if the stated focus is pain, then the practitioner should note down what type of pain, the location of pain and how patient feels under Data).  Action (A) – This represents the planning and implementation phase of the nursing process where completed or planned nursing interventions based on the assessment of the client’s status is described (for example, medicines, advices, exercises). Changes to the plan of care are also included in this section.  Response (R) – This section is the evaluation phase of the nursing process in which the impact of the interventions on client outcomes is described (for example, if pain is the focus, then the observation whether pain is relieved or not is mentioned under Response) Flow sheets and checklists are often used as an adjunct in order to document routine and ongoing assessments as well as observations including vital signs, personal care, etc. It is not required to repeat the information noted down on flow sheets in the progress notes.
  • 3. www.medicaltranscriptionservicecompany.com SOAP Charting SOAP charting uses a problem-oriented approach to documentation in which nurses first identify and list out patients’ problems and documentation is done on the basis of identified problems. This type of documentation is typically organized in the following manner:  Subjective (S) – Nurses document how the patient actually feels in this section such as symptoms, patients’ complaints, medication side effects and so on. The patient’s own words are used as much as possible.  Objective (O) – This section represents objective data including results of the physical exam, vital signs, lab results and studies.  Assessment (A) – In this section, the patient’s status such as the diagnosis, prognosis, treatment, and side effects is documented along with the patient profile (age, sex, occupation, martial status and significant characteristics)  Plan (P) – The medication strategy, planned tests and discharge plans are documented in this section. The section also discusses whether the plan stays the same or whether any changes are needed. Flow sheets and checklists are used frequently as an adjunct along with SOAP charting. Narrative Charting In this method, the patient’s status, nursing interventions and patients’ responses to those interventions are documented in chronological order covering a specific time frame. This information is typically included in progress notes and is supplemented by other tools including flow charts and checklists. It is required to document the patient assessments whenever the institution demands and more frequently when the following things are observed.
  • 4. www.medicaltranscriptionservicecompany.com  Change in the patient's condition  Patient’s response to a particular treatment or medication  No improvement in the patient's condition  Patient’s or family member's response to teaching It is required to document what you hear, observe, inspect, do or teach along with specific descriptive information as much as possible. You should also include notification to the physicians if changes occurred. The physician’s response, new orders that need to be followed and the patient’s response should be documented as well. You can use a head-to-toe approach to organize your notes or you can refer to the care plan and document the patient’ progress with respect to the plan and any unresolved problems. Whichever documentation method you select, make sure that it reflects client care needs and the context of practice. Certain institutions may combine elements of different documentation methods and formats. There should be a standard documentation procedure within the healthcare institution and if the institution changes its method or format, it should be done within the context of appropriate planning, involvement of nurses and their education. Accurate and standard documentation improves the communication between physicians and nurses, promotes good nursing care and helps to meet professional and legal standards. Contact MTS Transcription Services 8596 E. 101st Street, Suite H Tulsa, OK 74133 Main: (800) 670 2809 Fax: (877) 835-5442