Understanding the different types of nursing documentation and how to identify them is essential when reviewing medical records for a case. The Joint Commission will accept any form of compliance regarding the type of documentation (2021). For this reason, there are many options available for use and it is imperative that those working with and are in review of medical records understand each type of documentation method.

In all documentation by a Registered Nurse, or licensed practical nurse the Nursing Process must be adhered to although not all documentation methods are the same. You may see or hear terms or acronyms such as DAR, APIE, ADPIE, SOAP, or SOAPIE for example. All forms require demonstration of Assessment, Diagnosis (nursing not medical), Planning, Intervention, and Evaluation.

Here’s a breakdown of the common types of nursing documentation, what they include, how to recognize them, and key tips for attorneys who work with medically related cases.

1. Narrative Nursing Notes

Overview:
Narrative notes provide a chronological, free-form account of a patient’s care and interactions with healthcare providers. They include detailed descriptions of the nurse’s observations, patient responses, and any actions taken. They include details about the plan of care, provider orders, and more.

How to Recognize narrative notes:

• Written in paragraph form

• Provides a running log of events, timestamped and dated

• Look for phrases about patient condition or treatments (e.g., “Patient reported pain in lower abdomen,” “Administered 5 mg morphine at 11:30 am”)

Key Tip for Attorneys:

·        Narrative notes can be a goldmine for tracking the timeline of care and uncovering discrepancies

·        Look for repetition, out of order entries, or duplication

·        Check for any vague language or gaps in time between entries

·        Look for crossed out or scribbled out entries

2. Flow Sheets

Overview:
Flow sheets are structured,  grid-like forms used to record routine assessments and observations, such as vital signs, pain levels, neuro assessments, fall risk evaluations, safety interventions, and intake/output of fluids.

How to Recognize:

• Highly organized, tabular format

• Focus on specific areas of patient care (e.g., a vital signs flow sheet will list temperature, pulse, and blood pressure over time, skin assessment will list out color, temperature, breakdown)

• May include standardized checkboxes or dropdown selections

• May include a space for a brief narrative comment

• In electronic format will refer to another section of the record for narrative entries to explain in more detail

Key Tip for Attorneys:

·        Provide objective data on patient status over time

·        Look for patterns that indicate deterioration or inconsistencies between vital signs and the narrative documentation

·        Look for gaps in documentation, late entries

·        Look for consistency with provider orders

3. Electronic Health Record (EHR) Audit Trails

Overview:
Audit trails track all electronic interactions with a patient’s medical record, including who accessed it, what changes were made, and when. They serve as an invaluable resource for tracking modifications or omissions in the record

How to Recognize:

• Only available in digital format (never a pdf)

• All health care organizations are required to produce easily

• Logs actions such as document creation, editing, or deletion

• Timestamped and associated with the name or ID of the staff member who made the changes

Key Tip for Attorneys:

·        Always request audit trails in electronic excel format

·        Request audit trails for cases where the accuracy of documentation is in question.

·        Look for late entries or backdated documentation

4. SOAP or SOAPIER Notes

Overview:
SOAP (Subjective, Objective, Assessment, and Plan) notes are structured around four key elements, offering a focused, concise way of recording patient care.

• Subjective: What the patient reports (e.g., pain levels, symptoms)

• Objective: Observable data (e.g., physical exam findings, vital signs)

• Assessment: The nurse's clinical judgment or diagnosis based on the subjective and objective data

• Plan: The plan for care, including treatments or follow-up actions

• Intervention: Application of the plan of care, treatments, or follow-up actions

• Evaluation: Assessment or reassessment of the intervention

• Response: How the patient responded and recommendations for ongoing care

How to Recognize:

• Clearly labeled sections for Subjective, Objective, Assessment, Plan, Intervention, Evaluation, and Response.

• Often used in problem-oriented medical records (POMR).

• May be handwritten

Key Tip for Attorneys:

·        Provide clarity about the nurse’s thought process and clinical reasoning

·        Look for inconsistencies between the assessment and the plan

·        Look for a failure to close the loop between evaluation, response and assessment

5. Charting by Exception (CBE)

Overview:
In Charting by Exception, nurses only document findings that deviate from the norm, if all unstated aspects of care meet the facility's standards.

How to Recognize:

• Minimal documentation for routine care

• Focuses solely on abnormalities or changes in the patient's condition

• Often combined with flow sheets or checklists for normal findings

Key Tip for Attorneys:

·        Saves time for nurses

·        Includes potential omissions

·        Need to cross check other entries during critical periods for key details

·        Look for agency policy that communicates unstated “normal” conditions not required in documentation

6. Medication Administration Records (MAR)

Overview:
Medication Administration Records track the administration of drugs to the patient, including doses, times, and routes of administration.

How to Recognize:

• Typically found in a tabular or structured format

• Lists all prescribed medications, dosages, times, and methods of delivery (oral, intravenous, etc.)

• Includes areas for documentation of patient response to the medication

Key Tip for Attorneys:

·        MARs are crucial when dealing with medication errors or adverse reactions

·        Cross-reference the timing of medication administration with other nursing notes and flow sheets

·        Cross-reference the medication order with the medication administration

·        Look for proof of completion of the 5 rights and 3 checks (bar code scanning)

7. Incident Reports

Overview:
Incident reports are internal documents completed after an unexpected event, such as a patient fall, medication error, or equipment failure. While they are not part of the patient’s medical record. Incident reports are a safety tool not meant to end up in court. But sometimes they do.

How to Recognize:

• Not always found in standard medical records

• May need to be specifically requested during discovery

• Documents the facts surrounding an adverse event

Key Tip for Attorneys:

·        They may be discoverable in certain cases

·        These reports can reveal early acknowledgment of an error or negligence

·        Should not contain opinion only objective facts

·        Should not be identified in the patient care record as existing

8. Discharge Summaries

Overview:
Discharge summaries detail the patient’s condition at the time of discharge, including any instructions for home care, medications, follow-up appointments, and the patient’s final status.

How to Recognize:

• Written at the end of the patient’s hospital stay or care episode

• Includes key information about the patient's diagnosis, treatment, and follow-up care instructions

Key Tip for Attorneys:

·        Discharge summaries can indicate whether appropriate instructions were provided

·        Can help determine if the patient was discharged prematurely

·        Review for any signs of hasty discharge or failure to ensure continuity of care

·        These are not the complete medical record

Conclusion

Understanding the different types of nursing documentation is crucial for personal injury and medical malpractice attorneys. Whether you're investigating deviations in care or defending against claims, knowing how to identify and interpret these records will provide you with invaluable insights.

By being diligent in your review of nursing documentation, you can uncover critical details that either strengthen your case or support your defense.

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Reach out to UPvision Consulting now to get started on bridging the gap between medicine and law with confidence and clarity. Visit our website or call us directly to schedule your consultation!

References:

C. R. Taylor, P. B. Lynn, & J. L. Bartlett (2023). Fundamentals: The Art and Science of Person Centered Care. Wolters Kluwer. Mexico. ISBN: 1975168151

https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf

https://www.jointcommission.org/standards/standard-faqs/home-care/leadership-ld/000001198/

Murphy EK. Incident reports may or may not be privileged information. AORN J. 1990 Mar;51(3):851-2, 854. doi: 10.1016/s0001-2092(07)66632-0. PMID: 2317035.

https://www.nso.com/Learning/Artifacts/Articles/Incident-reports-A-safety-tool

https://pressbooks.library.torontomu.ca/documentation/chapter/methods-of-documentation/