Charting

Discussion Question

With the move to electronic medical records (EMR) and electronic health records (EHR), software vendors have developed methods and formats to enter data. Research “types of charting in electronic records,” and discuss one type to include pros and cons. How is it similar to paper charting? How is it different? Provide one reference to support your discussion.

Discussion Question:

Research types of charting, and discuss one that you feel is the best and why you chose it. Would it work in all areas of medicine and why? Provide one reference to support your discussion.

Assignment Module 5

Assignment Instructions

1. Quiz – Section 5 & 6
2. This assignment has 3 parts to it:
   1. Write a 1000-word essay summarizing each of the two different charts below, how they will be used in your chosen career, proposed improvements and better ways this information could be conveyed. Separate each section in your paper with a clear heading that allows your professor to know which bullet you are addressing in that section of your paper. Support your ideas with at least one (1) citation in your essay. Make sure to reference the citations using the APA writing style for the essay. The cover page and reference page do not count towards the minimum word amount. Review the rubric criteria for this assignment.

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1. SOAP Charting
   1. Your assignment is to include the list below and put the items in a SOAP format. You will want to research to find a form of your choice. You may add words to make sentences out of some of these items. When you get done, you should be able to view the notes and have a picture of this patient and know the next steps. Make sure that you have the needed information from your research of SOAP notes.
      1. John Smith, DOB 08-10-1951 came into the clinic to see Dr. Jerry Jones. Below are notes taken during Mr. Smith’s visit.
      2. Blood Pressure: 165/85
      3. Patient complains of left arm pain.
      4. Complains of leg weakness and increases with going up steps
      5. Diagnosis: Hypertension, bilateral edema legs, and ankles, Heart Disease, Diabetes
      6. Elevate legs for 1 hour 4 times a day
      7. Height: 182 cm
      8. Inflammation on both lower legs
      9. Pain is aching
      10. Pain is better when I elevate my legs
      11. Pain is worse at night
      12. Peripheral edema, both ankles
      13. Prescribe Hydrochlorothiazide, 25 mg tablet, 1 per day in the am.
      14. Pulse Oximetry: 97%
      15. Pulse: 60 bpm
      16. Rate pain 5 out of 10
      17. Respiration: 16 bpm
      18. Return for follow-up in two weeks
      19. Temperature: 98.5
      20. Wear support stockings till next appointment
      21. Weight: 165 kg
      22. X-rays show no fractures
2. PIE Charting Assignment
   1. Review the bottom of page 160 of your text for patient charting using the PIE method. Using your creative mind, create a problem, provide interventions, and identify the results (evaluation). Your problem should include a paragraph (min 100 words), interventions (at least two – min 100 words) and evaluation is a paragraph (min 100 words).

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Assignment Expectations

Length: 1000-word essay plus each of the charts.

Structure: Submit the appropriate format for each item. Include a title page and reference page in APA style. These do not count towards the minimal word amount for this assignment.

References: Use the appropriate APA style in-text citations and references for all resources utilized to answer the questions. Include at least one (1) scholarly citation to support your claims.

Format: Save your assignment as a Microsoft Word document (.doc or .docx).

File name: Name your saved file according to your first initial, last name, and the assignment number (for example, “RHall Assignment 1.docx”)

SAMPLE DISCUSSION POSTS AND ASSIGNMENT

Discussion 1

There are three main types of electronic records. They include electronic health records, personal health records, and electronic medical records. The charting I would discuss is electronic health records. EHRs are the digital version of a patient’s paper chart. EHRs make information readily available to healthcare professionals when they need it securely and safely.  EHRs automate and streamline provider workflow and provide access to evidence-based tools that can be used by healthcare providers to make important decisions. EHRs also contains patients’ medical diagnosis, medical history, treatment plans, allergies, immunization dates, and many more (Shi et al., 2020).

The first advantage of EHR is that it can be used to provide complete, up-to-date, and accurate information about patients before receiving care. EHRs also make it easy for healthcare professionals to coordinate efficient care. It also helped healthcare organizations comply with HIPAA rules (Shi et al., 2020). The rule requires that health information should be kept secure and away from unauthorized people. It provides safer care, reduces medical errors, and improves patient diagnosis. It also enabled more reliable and safer prescribing, improve provider and patient communication and interaction, and well as healthcare convenience. It helps providers improve work-life balance and improve productivity. The main disadvantage of EHR is its upfront cost (Koleck et al., 2019). It is highly costly to implement EHR in a healthcare facility. It is similar to paper charting since more have patient information. Both collect data about a patient. However, EHR is more efficient and effective than a paper chart.

References

Koleck, T. A., Dreisbach, C., Bourne, P. E., & Bakken, S. (2019). Natural language processing of symptoms documented in free-text narratives of electronic health records: a systematic review. Journal of the American Medical Informatics Association, 26(4), 364-379.

Shi, S., He, D., Li, L., Kumar, N., Khan, M. K., & Choo, K. K. R. (2020). Applications of blockchain in ensuring the security and privacy of electronic health record systems: A survey. Computers & security, 97, 101966.

Discussion 2

There are many types of charting in healthcare. The best charting format for me is SOAPIE Charting. SOAPIE means subjective, objective, assessment, plan, implementation, and evaluation. I feel that SOAPIE note is the best charting method since it captures almost all needed health information about a patient (Nicholson & Johnson, 2020). SOAPIE charting can be used by any healthcare professional for documentation of any interaction with patients and their family members from intake consultations to inpatient procedures. It has information about the patient’s presenting symptoms, medical history including initial diagnosis and treatments, and the patient’s lifestyle. Healthcare does not need any other document if present with a patient’s SOAPIE. The document also has interventions that have been proposed and any other recommendations. SOAPIE notes also include information about the family’s medical and psychiatric history (Nicholson & Johnson, 2020). A healthcare professional can trace a pattern in a disease by looking at the patient’s family health history provided in the SOAPIE note.

I also choose SOAPIE because it is most effective when working with patients who visit different healthcare providers regularly. The other healthcare provider will not have a difficult time because the note provides that with enough information they can use to understand the patient. The charting system can be used by all healthcare professionals in all departments. I also like SOAPIE because it is arranged in a way that the healthcare professional can find information easily (Nicholson & Johnson, 2020). It makes the most relevant clinical medical records easy to find. However, it takes time to develop since a lot of information is often involved.

Reference

Nicholson, C., & Johnson, K. (2020). Unlocking the power of school nursing documentation. NASN School Nurse, 35(4), 203-207.

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Assignment: SOAP Charting and PIE Charting

Charting is a significant practice in healthcare. It ensures that healthcare professionals capture all their actions and decisions regarding patient care. Charts prepared by healthcare professionals are often used for future reference or during the referral period. The purpose of this essay is to discuss SOAP Charting and PIE Charting and how they can be used to improve patient care.

SOAP Charting

SOAP note stands for Subjective, Objective, Assessment and Plan. The SOAP note is a method commonly used by healthcare professionals to document (Gogineni et al., 2019). It provides healthcare professionals with the opportunity to document patient data in an organized and structured way. SOAP note charting was developed by an American physician known as Larry Weed 50 years ago (Gogineni et al., 2019). The note reminds healthcare professionals of specific tasks they need to undertake while providing a model for evaluating data. The documentation also provides clinicians with a cognitive model of clinical reasoning. It helps guide healthcare professionals apply their clinical reasoning in assessing, diagnosing, and treating a patient based on the data they have been provided. SOAP notes also provide an essential piece of data about a patient’s health status. It also acts as a way of communication between healthcare professionals. The structure of SOAP notes is a checklist that serves as a potential index and a cognitive aid to receive data for learning from patient records.  

SOAP note has four main parts. The first part is subjective. Data for this part comes from the patient’s personal views, experiences, and feelings. Data for this part can also be retrieved from a person close to the patient (Andrus et al., 2018). This part provides context for lab tests to be ordered, assessed, and plan. The information included in this part includes the chief complaint, history of presenting illness, medical history, social history, family history, review of symptoms, current medications, and allergies. The chief complaint is the problem the patient presents within the healthcare setting (Andrus et al., 2018). Subjective data is the foundation of patient care. Without the information in the subjective data, a healthcare professional cannot provide effective care. 

The second part is objective. This section contains objective information collected by healthcare professionals. Information that can be included in this section includes physical exam findings, vital signs, imaging results, laboratory data, and other diagnostic data. Review and recognition of the documentation of other healthcare providers are also included in the objective section (Gogineni et al., 2019). A common mistake clinicians often make is including symptoms in the objective section. Symptoms are patients’ subjective descriptions of how they feel and thus should be included in the subjective section. An example of a symptom is when a patient says she feels weak. A sign is an objective finding by a clinician and should be included in the objective section. An example of a sign is abdominal tenderness to palpation.

The third section is assessment. This section is developed by synthesizing objective and subjective evidence to make a diagnosis. Clinicians assess the patient’s status by analyzing the subjective and objective evidence and develop possible problems that can be the cause of signs and symptoms. This section has a list of problems, differential diagnoses, and possible diagnoses (Andrus et al., 2018). The last part is planning. In this section, the clinician includes information about additional tests and recommendations to address the illness. The clinician states needed tests, recommended treatment, referral, and any follow-up care in this section. Patient education and counseling are also included in the section.

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PIE Charting

PIE charting is a method used by healthcare providers to record the medical progress of a patient. This charting method is similar to SOAP approach because it is a problem-oriented charting approach. PIE stands for “P-Problem Identification, I-Interventions, and E-Evaluations” (De Groot et al., 2019, pg. 1). When charting using this format, the notes are numbered based on the patient’s problems. The PIE charting method helps nurses ensure that their diagnosis is documented in the form of problem, intervention, and evaluation. The documentation method improved the accuracy and quality of reporting in nursing. The method also improves the professional and scientific performance of a nurse. It also improves communication between healthcare professionals. For instance, during shifts, nurses get new patients (McCarthy et al., 2019). PIE documentation can help the nurse understand their new patient, the disease ailing the patient and proposed intervention to address the problem. PIE documentation also improves communication during the referral period.

PIE charting is done by a nursing team who helps provide care to patients. The chart shows the nursing diagnosis, interventions, and evaluation of the interventions. Flow forms of sheets are used to develop the chart and patients are assigned a number. Nurses should ensure that the abbreviation used is authorized and legible when developing the chart (McCarthy et al., 2019). The nurse should also ensure that the data in the chart is sequenced accurately, factual, and grammatically correct. The chart has three sections. The first section is problem identification. In this part, the nurse documents the health problem as reported by the patient. For instance, if a patient reports a severe headache, it should be documented in the problem section. The second section is intervention. In this section, the medical officer or nurse documents interventions implemented to address the problem (De Groot et al., 2019). The healthcare professional should highlight the test, medicine or any intervention provided to help the patient recover. For instance, if a blood test was taken and the patient is given a drug, it should be recorded in the chart. The last part is evaluation. In this section, the healthcare provider documents the feedback of the patient after treatment (De Groot et al., 2019). It carries information collected during the follow-up period. For instance, if the patient reported with headache, it should be stated whether it is lessened.

Conclusion

SOAP provides healthcare professionals with the opportunity to document patient data in an organized and structured way. Its main parts include subjective, objective, assessment, and plan sections. PIE charting is a method used by healthcare providers to record the medical progress of a patient. The PIE charting method helps nurses ensure that their diagnosis is documented in the form of problem, intervention, and evaluation.

References

Andrus, M. R., McDonough, S. L. K., Kelley, K. W., Stamm, P. L., McCoy, E. K., Lisenby, K. M., Whitley, H. P., Slater, N., Carroll, D. G., Hester, E. K., Helmer, A. M., Jackson, C. W., & Byrd, D. C. (2018). Development and validation of a rubric to evaluate diabetes SOAP Note writing in APPE. American Journal Of Pharmaceutical Education, 82(9), 6725. https://doi.org/10.5688/ajpe6725

De Groot, K., Triemstra, M., Paans, W., & Francke, A. L. (2019). Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews. Journal of Advanced Nursing, 75(7), 1379-1393.

Gogineni, H., Aranda, J. P., & Garavalia, L. S. (2019). Designing professional program instruction to align with students’ cognitive processing. Currents in Pharmacy Teaching & Learning, 11(2), 160–165. https://doi.org/10.1016/j.cptl.2018.11.015

McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett‐Collins, G., Clancy, M., & Savage, E. (2019). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of Nursing Management, 27(3), 491-501.