5. Documentation Frameworks

Several methods of documentation are used to organise a nurse’s or midwife’s progress notes. Decisions about which method or framework you use may depend on the facility’s policy and procedural guidelines for documentation. Otherwise, it is a matter of personal preference.

In this section,  four documentation frameworks are presented: charting by exception, narrative,  problem-focused, and systems-based documentation. Another method that is sometimes used to inform documentation is ISBAR (Identification/Introduction, Situation, Background, Assessment, and Recommendation), however this framework is typically used for verbal communication such as handover.

Charting by exception

Charting by exception (CBE) may be used in some health care facilities, particularly when a clinical (care) pathway or care plan has been implemented to inform and guide the care provided to the person. With CBE, the length and duplication of information are reduced as the healthcare team will follow a pre-determined treatment plan (i.e., a clinical pathway). While a health professional may need to make small notations about some aspects of care (e.g., ticking, initialling and dating when a specific assessment or intervention has occurred), the health professional will only expand on their documentation when a variation in the anticipated findings, routine care or care outcomes transpire. For example, the anticipated finding for a post-surgical pathway may be no signs of wound infection.  If the person’s postoperative wound showed no signs of infection during the dressing change, the nurse who was using a CBE approach would indicate the wound care was performed on the pathway but there would be no need for them to provide additional information about the appearance of the wound on the post-operative surgical pathway or progress notes. In contrast, if the nurse found signs of a possible wound infection they would need to make additional notes in the person’s health record to describe their observations of the wound. For example, indicating whether the wound is exhibiting signs of infection such as redness, swelling, and/or purulent discharge.

Narrative documentation 

Narrative documentation uses a chronological approach whereby information is documented in a  storied format and sequential order. For example, you would document when the person’s symptoms first started, what interventions were initiated and why, and how the person responded to these interventions.  A storied format involves attending to ‘the what,’ ‘when,’ ‘who,’ and ‘how’ of the event that you are documenting about such as describing what happened when it happened, who was involved, how the person responded and so forth. For example: ‘Joan is an 8-year-old girl who fell off her bike while riding with her mother, Jessica, to the corner store. Jessica reports Joan experienced a loss of consciousness for approximately 10 seconds and was confused when she awoke. Joan then voiced to Jessica that she had “I have a sore head, Mummy” within 20 minutes of the fall. Jessica brought Joan to the emergency department within 40 minutes of the fall.’ As you can see, this example is both chronological and storied.  Traditional narrative style documentation must also include any change in the person’s condition and their response to the treatment or care provided.

Problem-focused documentation

Problem-focused documentation uses the nursing process (or the process of woman-centred care) to inform the nurse or midwives’ reporting of patient care delivery and outcomes.  Using this approach, the nurse focuses on the person’s issue/concern/problem including describing what assessment data was collected to evidence this problem. The nurse will then outline the plan of care that was used to address the problem and the evaluation criteria used to assess the care plan’s effectiveness.  Several mnemonics can be used to inform this documentation style:

• Focus charting or DAR (data, action, response) or DAE (data, action, evaluation)
• AIR (assessment, intervention, response)
• APIE (assessment, plan, intervention, evaluation)
• SOAP (subjective, objective, assessment, plan) and its derivatives including:
  • SOAPIE (subjective, objective, assessment, plan, intervention, evaluation)
  • SOAPIER  (subjective, objective, assessment, plan, intervention, evaluation, revision)

Table 5 presents an overview of each of these frameworks.

Systems-based documentation

Systems-based documentation uses a framework where information related to the person’s current concerns and related assessment data is recorded against each specific body system.  The body systems typically reported include the central nervous system (CNS), cardiovascular system (CVS), respiratory system (Resp), gastrointestinal system (GIT), metabolic, genitourinary (GUT), integumentary (Skin), musculoskeletal (MSK). The person’s experience of pain and its management may be reported under CNS or the affected body system. Appendix 1 provides an example of data that may be included under each of these systems. When using this approach, the nurse may also report additional data about the person (e.g., wellbeing, support structures) and their care (e.g. additional procedures planned/performed, discharge considerations) using headings such as other,  psychosocial, care planning, or discharge planning.   A midwifery systems approach for an antenatal assessment is also included in Appendix 2.

An example of a completed progress note using this format is presented in Appendix 3.  There is also an example of a poorly constructed progress note in Appendix 3.  See how many mistakes you can identify in this example.