A charting system developed to eliminate lengthy narrative notes. During the nursing assessment, a form is completed which defines all normal parameters for each body system. If the patient meets these, the nurse enters only a check mark on the form. Notes are written only for abnormal findings. A care plan is created and written in longhand, using the SOAPIER format: S = subjective data, O = objective data, A = assessment, P = plan, I = interventions, E = evaluation, and R = revisions. Care plan problems are numbered and followed. Day-to-day care is documented on forms, using check marks, and shorthand notes are used for treatments and other nursing or physician orders. Only exceptions are charted in narrative form. The system was developed in 1983 at St. Luke’s Medical Center in Milwaukee, Wisconsin.<\/p>\n
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A charting system developed to eliminate lengthy narrative notes. During the nursing assessment, a form is completed which defines all normal parameters for each body system. If the patient meets these, the nurse enters only a check mark on the form. Notes are written only for abnormal findings. A care plan is created and written […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3],"tags":[],"class_list":["post-143869","post","type-post","status-publish","format-standard","hentry","category-c"],"yoast_head":"\n