It is an essential and important practice to have a detailed history of the patient visiting the doctor recorded in a proper way such that the health condition is carefully monitored and the best possible treatment is provided to the patient.
Documenting the history of the patient’s health and progress can also help in the event of legal issues as well and, as such, adequate importance is given to this important task.
Normally, it is the responsibility of the certified nursing assistant or a qualified nurse, to document the patient’s history or chart the developments in the patient’s health in a methodical way.
Depending upon the policy of the management, various types of charting are followed. Some of them include SOAP Charting and DAR charting. These are the latest additions or innovations of recording patient’s history. Apart from these latest types, there are other types of charting as well – such as Exception Charting, and Narrative Charting.
One of the oldest forms of recording history of a patient is none other than the Narrative Charting. Also referred to as the source-oriented charting, it gives the freedom to the nurse not to stick to any format, but record the details in a logical manner. The narrative charting allows the nurse to record the observations, data, as well as reactions from the patient, not in a specific pattern, but in a sequential or chronological manner, relying on nurse’s observations and treatment. All that a nurse has to ensure in narrative charting is just follow the general guidelines and not to leave any blank space in between in the documentation.
Another form of documentation or charting that is in vogue is called as the Exception Charting. The certified nursing assistant or the qualified nurse, as part of normal routine, has to carry out certain common tasks such as checking the blood pressure, pulse reading, fever, normal excretion and such other things. The nurse is responsible for these routine activities and might not require specific mention in the charting process as long as the situation is normal or not deviating from the normal routine. In Exception charting, the nurse is required to record only the abnormalities or things that are not normal in the patient’s history, leaving the normal things to be presumed as carried out otherwise without any problem. The nurse, in case of reporting abnormalities, can use any type of charting such as the DAR charting or the SOAP charting for the abnormalities and supplement it with the normal general documentation.