Which forms of nursing documentation use the nursing process through problem-oriented charting?
a. charting by exception and critical pathways
b. computerized documentation and point-of-care charting
c. narrative and source-oriented charting
d. SOAP (-IE, -IER) and PIE charting
D
The problem-oriented medical record (POMR) uses a logical system of making entries: subjective data, objective data, assessment (conclusions drawn from client data), and plan (actions to be taken); this system is known as SOAP charting. In some facilities, additions to the SOAP system include implementation and evaluation or implementation, evaluation, and revision (SOAPIE and SOAPIER, respectively). The critical components of the problem-oriented record include the database (assessment data); the problem list (client's acute, chronic, active, or inactive problems); an initial plan (goals, expected outcomes, and learning needs); and progress notes using the SOAP, SOAPIE, or SOAPIER format. Reflecting a streamlined version of the SOAP format, PIE charting includes the components of problem, intervention, and evaluation. Assessment flow sheets, nurses' progress notes, and an integrated plan of care are key components of the PIE system.
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