Which nursing documentation best meets the requirement for problem-oriented charting?
a. "Pacing and muttering to self. Sensory perceptual alteration related to internal auditory stimulation. Given fluphenazine 2.5 mg PO at 0900 and went to room to lie down. Calmer by 0930 . Returned to lounge to watch TV."
b. "Agitated behavior. Patient muttering to self as though answering an unseen person. Given haloperidol 2 mg PO and went to room to lie down. Patient calmer within 30 minutes. Returned to lounge to watch TV."
c. "S: States ‘I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol 2 mg PO. I: Haloperidol 2 mg PO given at 0900 . E: Returned to lounge at 0930 and quietly watched TV."
d. "Pacing hall and muttering to self as though answering an unseen person. Haloperidol 2 mg PO administered at 0900, with calming effect in 30 minutes. Stated ‘I'm no longer bothered by the voices.'"
C
Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The distracters use PIE, focus, and narrative documentation.
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