APPENDIX Cl CHARTING NURSING CARE, PROGRESS NOTES AND CLIENT RESPONSES/ OUTCOMES* A. PURPOSES 1. Communicate care to other team members who need information on what the nurse has done and how the client is doing. 2. Help identify patterns of responses and changes in status. 3. Provide data for evaluation, research and improvement of quality of care. 4. Document data to supply validation for insurance or legal purposes. 8. TYPES OF CHARTING USING MNEMONICS 1. AIR-A (Assessment, Intervention, Response, Action). Chart the assessment data observed/gatliered, the interventions done, the client's response/s to the interventions and any action/s taken based on the response/s. 2. DAR (Data Action Response). Chart the data observed/gathered, the actions performed. and the response/s of the client. 3. DIE (Data, Intervention, Evaluatio n). Chart the data observed/ gathered, the interventions done and evaluation of the client's response/s. 4-Pi E (Problem, lnterventions, Evaluationj. Chart the status of the problem/s, the interventions performed and the evaluation of the client's response/s to the interventions. 5. SOAP, SOAPIE. Chart subjective data, objective data, analysis of assessment data to reflect nursing problem statement/s, intervention plan, ilnplei;nentation results and evaluation findings. 4 Adapted from Alfaro-Le Fevre, R. (2002). Applying Nursing Process: Promoting Collaoorative Care (s Edition). Fhiladelphia: Llppinoott Williams and Wilkens, pp. 149, 174 and 177. 451 