S: state he does not want to sit with or talk to others; they frighten me O: stays in room alone unless strongly

encouraged to come out; no group involvement; at time listens to group conversation from a distance but does not interact; some hypervigilance and scanning noted A: inability to trust; panic level of anxienty; delusional thinking I: initiated trusting relationship by spending time alone with the klien; discussed his feeling regarding interactions with others; accompanied client to group activities; provided positive feedback for voluntary participating in assertiveness traning Focus Charting Another type of documents that reflects use of the nursing process is Focus Charting, focus Charting differs from POR in that the main perspective has been changed from masalah to focus, and data, action, and response (DAR) has replaced SOAPIE. Lampe (1955) suggests that a focus for documentation can be any of the following: I. Nursing diagnosis 2. Current client concern or behavior 3. Significant change in thy client status or behavior 4. Significant event in the client s therapy The focus cannot be a medical diagnosis. The documentation is organized in the format of DAR. These categories are defined as follos D= Data: information that supports the stated focus or describes pertinent observations about the client A= action: immediate or future nursing action that address the focus, and evaluation of the present care plan along with any change required R: response: description of client s responses to any part of the medical or nursing care

D: states he does not want to sit with or talk to other; thy frighten him; stay in room alone unless strongly encouraged to come out; no group involvement; at times listens to group conversations from a distance, but does not interact; some hypervigilance and scanning noted A: initiated trusting relationship by spending time alone with client; discussed his feeling regarding interactions with other; accompanied client to group activities; provided positive feedback for voluntarily participating in assertiveness training

R: cooperative with therapy; still acts uncomfortable in the presence of a group of people; accepted positive feedback from nurse

Validation of the nursing process with focus charting Information that supports the stated focus or describes pertinent observations about the client A nursing diagnosis; current client concern or behavior; significant change in the client status; significant event in the client s therapy. NOTE: if outcome appears on written care plan, it need not be repeated in daily documentation unless a change occurs. Immediate or future nursing actions that address the focus; appraisal of the care plan along with any change occurs. Description of client responses to any part of the medical or nursing care Table 9-4 show how focus charting corresponds to the steps of the nursing process. Following is an example of a three-column documentation in the DAR format.

The PIE Method PIE, or more specifically APIE (assessment, problem intervention, evaluation), is a systematic method of documenting to nursing process and nursing diagnosis. A problem-oriented system, PIE charting uses accompanying flow sheets that are individualized by each institution. Criteria for documentation are organized in the following manner: A = Assessment: A complete client assessment is conducted at the beginning of each shift. Results are documented under this section in the progress notes, Some institutions elect instead to use a daily client assessment sheet designed to meet specific needs of the unit. Explanation of any deviation from the norm is included in the progress notes. P = Problem: A problem list, or list of nursing diagnoses, is an important part of the APIE method of charting. The name or number of the problem being addressed is documented in this section I: intervention: nursing action are performed, directed at resolution of the problem E = Evaluation: outcomes of the implemented intervention are documented, including an evaluation of client responses to determine the effectiveness of nursing intervention and the presence or absence of progress toward resolution of a problem. Table 9 5 shows how APIE charting corresponds to the steps of the nursing process. Following is an example of a three-column documentation in the APIE format.

Validation of the nursing process with APIE method Subjective and objective data about the client that are gathered at the beginning of each shift Name (or number) of nursing diagnosis being addressed from written problem list, and identified outcome for that problem: NOTE: if outcome appears on written care plan, it need not be repeated in daily documentation unless a change occurs. Nursing actions performed, directed at problem resolution Appraisal of client responses to determine effectiveness of nursing interventions.

A: states he does not want to sit with or talk to other; they frighten him; stay in room alone unless strongly encouraged to come out; no group involvement; at times listens to group conversations from a distance but does not interact; some hypervigilance and scanning noted P: social isolation related to inability to trust, panic level of anxiety, and delusional thinking I: initiated trusting relationship by spending time alone with client; discussed his feelings regarding interactions with other; accompanied client to group activities; provided positive feedback for voluntarily participating in assertiveness training E: cooperative with therapy; still uncomfortable in the presence of a group of people; accepted positive feedback from nurse.

Electronic Documentation Most healthcare facilities have implement-or are in the process of implementing- some type of electronic health records ( EHR) or electronic documentation system. EHRs have been sjown to improve both the quality of client care and the of the healthcare system (Hopper & Ames, 2004). In 2003, the U.S. Department of Health and human services commissioned the institute of medicine (IOM) to study the capabilities of an HER system. The IOM indentified a set of eight core functions that HER system should perform in the delivery of safer, higher quality, and more efficient health care. These eigh core capabilities include the following (tang, 2003) o Health Information and Data. EHRs would provide more rapid access to important patient information (e.g., allergies, lab test results, a meditation list, demographic information, and clinical narratives). Thereby improving care providers ability to make sound clinical decisions in a timely manner o Results Management. Computerized results of all types (e.g., laboratory test results, radiology procedure result reports) can be accessed more easily by the provider at the time and place they are needed.

o Order Entry/Order Management. Computer-based order entries improve workflow processes by eliminating lost orders and ambiguities caused by illegible hard writing, generating related orders automatically, monitoring for duplicate orders, and improving the speed with which orders are executed. o Decision Support. Computerized decision support systems enhance clinical performance for many aspects of health care. Using reminders and prompts, improvement in regular screenings and preventive practices can be accomplished. Other aspect of healthcare support include identifying possible drug interactions and facilitating diagnosis and treatment. 0 Electronic communication and Connectivity. Improved communication among care associates, such as medicine, nursing, laboratory, pharmacy, and radiology, can enhance client safety and quality of care. Efficient communication among providers improves. Paper Advantages People know how to Use it. It is last for current practice. It is portable. Iris non breakable. It accept multiple data types, such as graphs, photographs, drawings, and text Legal issues and costs are understood Disadvantages it can be lost It is often illegible and incomplete It has no remote access It can be accessed by only one person at a time It is often disorganized Information is duplicated It is hard to store It is difficult to research, and continuous quality improvement ia laborious Same klient has separate records at each facility (phisician office, hospitaal, home care).

Records are shared only through hard copy

Advantages Can be accessed by multiple providers from remote sites Facilitates communication between disciplines Provides reminders about completing information Providers warning about incompatibilities of medications or variances from normal standard Reduces redundancy of information Requires less storage space and more difficult to lose Easier to research for audits, quality assurance, and epidemiological surveillance. Provides immediate retrieval of information Provides links to multiple database of healthcare knowledge thus providing diagnostic support. Decreases charting time Reduces errors due to illegible handwriting Facilitates billing and claim procedures.

Disadvantages Excessive expense to initiate the system Substantial learning curve involved for new users; training and re-training required Stringent requirements to maintain security and confidentiality Technical difficulties are possible Legal and ethical issues involving privacy and access to client information Requires consistent use of standardized terminology to suppport information sharing across wide network.

Continuity of care, allows for more timely intervention, and reduces the risk of adverse events. o Patient support. Computers-base interactive client education, self-testing, and self-monitoring have been shown to improve control of chronic illnesses o Administrative Processes. Electronic scheduling systems increase the efficiency of healthcare organization and provide more timely service to patient. 0 Reporting and Population Health Management. healthcare organizations are required to report healthcare data to government and private sectors for patient safety and public health. Uniform electronic data standards facilitate data process at the provider level, reduce the associated costs, and increase the speed and accuracy of the data reported. Table 9 6 lists sonic of the atlvaot.tgcs a tad d tools an sages of paper records attn Fl{Rs. SUMMARY AND KEY PUIN LS ci tih nutting process pctss siles .u titetltoulolugy by scisich nurses osay delives case ttotttg a s stetuatic, scientihc a ag to ac Ii 0 The focus of oursiog process is go ii slit cited asad bascd on a dcrssioss nsalwsg or isrohiets sols iag stindel, cstnsistiog of ott steps: .cssesstuetit, di,tg,sttsss, sittcc,tuae ideistihies tson , planstiog, isoplessscnt.stiuss, and evaluation. ci Aasessssaestt is a systeritatie, dynsnaic process by schi, It the sits se th rossgh interaction with the client, sig ui, caut others, anti iteahthcare prositlets, collects assd ii: lyees data abut the tfesst ci Nursing diagnoses sue clinical judgments shout ci ii vidoal, family, or entouusinity responses to srtti.i potential health problettss/ltfe processes. ci Outcomes are nseasctcshie, espected, paoeom-hto o goals that trassslsme into obseceable behaviors. ci Evaluation is the process of determining both 5 elieot s progress tosrard the attainment of tsp: t outcontes sod the effectivtocss of nursing rate. ci The psyclsiatric nurse uses die ntmrsiog process ti . rlieots to adapt sssecessfsahly to stressors ssithtta this eovtroomsaent. ci The nurse sers es as a valuable meosber of the it:,, ciplistary rce.stsnetmr teatom, trucking both inde1tc :i:i iitlc stid cot s1,eratirely ss ith other team naenabccs. ci f E ttu.i itage miteust is an innovative naodel ol i st unset p ilium set s es to provide quality chico t ti IC,, liii:

cutssrtalhimsg Isnaimbrare costs.. Critical pathsvavs ui , us (f:Pc:s) serve as the tools for provision of care itt . : tn toatiageitsettt system. ci Nurses naay serve as cate managers, arho are rcs1 :1,555- ble for negotiating srith multiple healthcarc ptisiiinss to obtain a variety of services for the client. o Concept mapping it a diagrammatic tearh:ttp .,nd learning soate y that ahlouu sttsdeuta and fact ta 50 visualize interrelationships bersveeo medical dsagiu set, isursiog diagnoses, assesssucsar data, auth trcatssaessss. Tise concept map care plan ma an i000vativc approach to planning and organizing otursing care. ci Nurses must doet.smeo r tls is tltr otti situ g Itt oesrss has been used in than she1 55cc) of care. 1 litre tttcmhsua,hs if docuismentation that diet S itsi I thte istirsisug process include ft() l, I outs (it itsi sip, atad 5 lii PIE metisod. ci Islany healthcare facilities have imoplesoented the use of electronic health records fEhIR) or electronic doeuoaeotaooo ayareuas. EHRs hare been ahosro to improve both the quality of client care and die ethciency of the healchcare system. roe odditienot clinical tools and study aids, visit ltootsgtus.