Author Question: You chart the following: (Problem) 1 pain related to surgical incision (Progress Note) S = States ... (Read 72 times)

cagreen833 · **on:** Jul 22, 2018

You chart the following: (Problem) 1 pain related to surgical incision (Progress Note) S = States discomfort in L hip; O = Grimaces with movement to L side Requests pain med q3 hours;

A = No change; P = Continue pain meds prn
This is an example of which type of charting?
1. DAR (Data, Action, Response)
2. SOAP (Subjective, Objective, Assessment, Plan)
3. APIE (Assessment, Problem Identification, Interventions, Evaluation)
4. charting by exception

Question 2

You chart the following: 7/16/00 0900 C/o sharp, constant pain in L hip, requesting pain medication. BP 98/50, P 62, R 10. Oriented 3. Responds to verbal stimuli but easily returns to sleep.

Need to wait for pain medicine explained due to low BP & resp. and length of time since last injection 3 hours (order is for q4 hours). Will reassess in 15 minutes. What type of documentation is this?
1. an explanation of why medication is withheld
2. admit note
3. observation of psychosocial status
4. client teaching note