Question

A nurse is introducing a group of newly licensed nurses to the various approaches to problem-oriented documentation.

Underlying Principles: List three common methods of problem-oriented charting with definitions of their acronyms.

Answer 1

Three common methods of problem-oriented charting are SOAP (Subjective, Objective, Assessment, Plan), PIE (Problem, Intervention, Evaluation), and FOCUS (Data, Action, Response), each with its unique format and focus. These methods aid in the systematic documentation and management of patient care.

Step-by-step explanation:

Common Methods of Problem-Oriented Charting

Problem-oriented charting is a systematic approach to documentation that emphasizes patients' problems. Here are three common methods of problem-oriented charting:

1. SOAP (Subjective, Objective, Assessment, Plan) - A method where the clinician records the subjective observations of the patient, objective findings, an assessment of the health problem, and the plan for treatment.
2. PIE (Problem, Intervention, Evaluation) - In this method, problems are identified, interventions are recorded, and then the patient's response to the intervention is evaluated.
3. FOCUS (Data, Action, Response) - This approach involves recording the data (F), action (O), and response (CUS) for the patient care and stands out for its emphasis on the nursing perspective.

Nurses are vital for ensuring that medical procedures are carried out safely and correctly. A notable example of collaboration between nurses and doctors in enhancing patient safety is the use of checklists in medical settings, a solution inspired by Dr. Pronovost's study in ICU. This approach, while simple in concept, addresses the complexity of human factors in medical care.