The Ultimate Guide to Nursing Charting: SOAP, PIE, DAR, and SBAR (NCLEX® MUST KNOW!)

Bad documentation in nursing school can literally put your patient's life and your nursing license at risk. So in this video, I'm walking you through five must know rules for perfect documentation that will make you a charting rock star in nursing school. Plus, we will also walk through the types of reports that the NCLEX loves, things like soap pie and SBAR reports. I'll also give you lots of critical thinking key points and examples to help you really critically think about all of it better on your exams. So hit that subscribe button and click the notification bell and let's dive in. All right, so you know how I love to make nursing content so simple for you. And when it comes to patient documentation, there is one really, really golden rule that is above everything that we do as nurses. And this is a huge NCLEX point for you. Okay? If you didn't document it, it didn't happen. All right? No documentation means you didn't do it. This isn't just some catchy catchphrase that your instructors like to throw around. This is literally the foundation of patient safety in nursing school and nursing legal accountability and team communication between the healthcare team. Even if you do the most perfect nursing assessment or give the most perfect medication and it correctly, if it's not documented in the patient's chart, it's invisible to everyone else. And it's invisible legally. Didn't happen, doesn't exist. So let's break this down into super simple steps that will make you a documentation rockstar, my friend. I've got five golden rules for you that will keep you and your patients safe. So I put all of these tips in my free clinical cheat sheet for you as well. So be sure to snag that the link is down below in the description. So I'll so the first rule of documentation is to document everything and do it right away. Not early, don't document late, but right away, after you do anything. Now here's a scary scenario for you to consider. Imagine that you give your patient their morning insulin dose before breakfast, but you get busy and you forget to chart it. And then a well meaning nurse colleague checks the chart, sees that the insulin was not given, and then administers a second dose. Now this could literally kill your patient from hypoglycemia, right? Huge, huge problem. So here's your key critical thinking point. Prompt documentation prevents medication errors for your patient and keeps the patient's record current. All right? So waiting until the end of your shift to chart for all of your patients during that day, that is a recipe for Disaster, my friend. And it's a legal nightmare just waiting to happen. Now, rule number two is to use a brain sheet. I love these. As a nursing student, you are soaking in so much information and there's just no way, no way that you're going to remember everything. So think of your brain sheet as kind of your GPS system for your assessments. So just like a GPS guides you turn by turn your brain sheet, it's going to guide you through each part of your head to toe assessment or your focused assessment. So jot down notes on your brain sheet during your nursing assessments with your patients, okay? This really creates a reliable reference when you go sit down to officially chart after your assessment. So trust me, this will save you so much time, it'll make your documentation way more smooth and reliable and accurate. Now, rule number three is to document the full cycle of patient care. This is huge for the nclex, my friends, they love testing this. So you need to document three things in order, all right? Assessment always comes first. Always document what you found before you do anything, like any nursing intervention or anything. Then the intervention, what action did you take? And then the patient's response. How did the patient respond to your nursing interventions? Now here's a memory trick. Think air, A I R assessment, intervention and response, all right? Just like you need air to breathe, we all do, you need air to document properly. Now let me give you an example here. If you check your patient's blood pressure and it's 180 over 100, so that's your assessment part. So document that. Then when you give their blood pressure medication, then that is what your nursing intervention would be. You give that blood pressure medication. So you document that it was given. Then you must go back about an hour, recheck their blood pressure, all right? And then you document that result. That's the response. So this cycle of your nursing assessment, intervention and response, this is critical for documentation and legal protection. Now, rule number four is to master your electronic health record system. So most facilities use an EHR system now, and here's the deal, the more you practice with these systems, the faster and more accurate that you will get at it. So take every single opportunity that you can to practice navigating your facility's ehr. So spending speed and accuracy and charting, it's going to make your life so much easier. So personally, I liked showing up to clinical early to get my patient assignment if they had it available for me. And I would flip through the patient's charts well before my clinical day even started. So if Your facility and if your school and your clinical instructor, if they allow that, doing that can be so helpful for you as you get used to the EHR system. And it will also really just give you a head start on your day because you, you already know what's going on with those patients that you have assigned to you that day. And rule number five is to only use approved abbreviations. This is a big one. So here's a critical thinking point for you, okay? Ambiguous abbreviations, these can be deadly. Imagine that you're trying to figure out what BLC LWR means. I don't like that one. Does it mean blood labs came back low, will repeat, or bed lowered, call light within reach? You can see why I don't like that one, right? Big NCLEX point here, my friend. When in doubt, write it out. So stick to your facilities approved abbreviation list and the Joint Commission guidelines. Write it out anytime you're doubtful. Abbreviations are a big deal. Now let's talk about documentation formats that you need to know. Now, the NCLEX loves testing some different documentation formats, so we're going to break these down for you to make it simple. The first one is flowcharts. These are grids, kind of for tracking trends and data like vital signs or blood glucose levels. So think of them as kind of like at a glance view of your patient's progress and how they're doing. Then you have narrative documentation. Now this is like a story that you're telling. It's chronological recording. So you'll use this for things like incident reports or significant changes in your patient's condition. And charting by exception or CBE is efficient, but it's tricky. You only document what's abnormal. So everything else with this one is assumed to be normal based on predefined standards. And you've got to know what those standards are. Now let's dive into problem oriented medical records or pomr, and the big three formats of the NCLEX loves for these ones. The first one is SOAP notes. So this is classic and it's comprehensive. So here's a memory trick. Think of washing your hands with soap. It cleans up all of the mess and it makes everything super clear. So here the S stands for subjective. So what the patient tells you their words, their feelings or their concerns. Subjective data. The O is objective data, the facts that you can measure. Things like vital signs, lab results and what you observe as the nurse. And then A is for assessment, your nursing diagnosis based on that subjective and objective data. And then the P is your plan so what are you going to do about it? Now let me give you a example to help this kind of come together and make more sense. So S subjective would be something like the patient states I'm worried about controlling the pain after my surgery. And then O for objective might be a heart rate of 98 beats per minute. The patient is restless and they're unable to sleep. And then your assessment could be anxiety related to fear of post operative pain management. And then P for your plan that could be something like educating the patient on the post operative pain medications, what they're going to be receiving, what times they'll be receiving it, and then some non pharmaceutical pain relief techniques that they could use to help relieve their pain. Now you can expand this to soapy and soapier by adding I for intervention, which is the specific actions that you implemented from your plan. And then E for evaluation, which is the patient's response to it. Something like the patient verbalized their understanding of the pain management plan and the patient was able to fall asleep. And then R for revision, which this would be any change to the plan if your interventions didn't work. Now the second format is pie. Pie, this is PI notes. This one is more streamed line streamlined. So think pie. It's as easy as pie, right? This format is different from SOAP because it doesn't restart state all the assessment data. It assumes that information is already documented in your flow sheets. So P is the problem, so your nursing diagnosis based on your assessment data. And then I is the intervention, so what you did. And then E is evaluation which is the patient's response. So here's an example of this one. P for problem might be anxiety and fear related to that post operative pain as evidenced by an increased vital signs and inability to sleep. And then I could be your actions that you took, right, the interventions to address the problem. And then E that evaluation would be the outcome of your interventions. Now the third format you've got to know is dar Dar. This is called focus charting. This focuses on a specific concern or event for the patient. So think dar like a dart hitting the target. It's a very, very focus. So D is data, subjective and objective info about the focus that you're focusing on. A is for action, which is your nursing intervention, and R is for the patient's response to those actions that you took. Now let me show you how this works with that pain management example. So D for data that could be like the patient grimacing and guarding their abdominal incision and they rate their pain as an 8 out of 10 they're requesting pain medication and then a for action that could be administered a medication, administer morphine, 2mg IV as ordered and then reposition the patient for comfort and then R. The response could be something like 30 minutes. Post intervention, the patient reports the pain is now a 3 out of 10 and appears more visibly relaxed. Now let's talk about professional communication and reporting. So this is between you and your colleagues. So clear communication is just as important as written documentation. As nurses, so whether you're giving report to the next shift or you're calling the doctor on call, structure is everything. We all want to follow kind of the same guidelines. So for your change of shift handoff report, your goal is for safe, seamless transition of care for your patient. So here's what to include. Basic patient info and diagnosis, current status and their recent progress, key details like vitals, meds, allergies, diet, activity and important upcoming plans that we need to do for this patient. And the SBAR framework is the standard for communicating with other members of the health care team. SBAR is tested heavily on the nclex, so you will definitely want to master this. My friend, my clinical instructor, would also have us actually give her our SBAR reports anytime that she asked. It was kind of scary, so that would really, really keep us on our toes. But it was really good practice. So S stands for situation. What is happening with the patient right now? B is background, so relevant context and history. And then A is your assessment, your objective and subjective data. And then R is the recommendation, what you need or want to happen. So recommendations for this patient. So let me give you an example. If you are calling the doctor, you say Dr. Smith, this is Nurse Christina, I'm on Fort West. I'm calling about Mr. Taylor in room 310. He's having acute difficulty breathing. Now that's the situation. So he's a 68 year old male admitted yesterday for pneumonia and he has a history of copd. Now that's the background. All right? Now his respiratory rate now is 28. His oxygen saturation dropped from 92 to 88% on room air and he has audible wheezing. Now that part is the assessment. And then I've started him on two liters of oxygen. I'm requesting an order for a stat breathing treatment and a chest X ray. Now that's the recommendation. So for telephone communication, here is a big NCLEX point. All right? Telephone orders, they're high risk. So here's your safety protocol. If you can have a second nurse listen in. If at all possible, you want to repeat the entire order back, spell out medication names and question anything, anything that seems wrong, and ensure that the provider signs the order within 24 hours. So here's a key critical thinking point for you. Always have all your data ready before calling. All right? Be professional. We want to be accurate and we want to document who we spoke with, when we spoke with them, and what was talked about on that call. The NCLEX Loves patient safety question and documentation is a huge, huge part of that. So if you struggle with answering NCLEX style questions in nursing school and choosing the most correct answer on your exams, you definitely want to check out this video here where I walk you through the absolute top strategies for choosing the correct answer on your nursing school exams. And if you like step by step guides for nursing school like this one, write love in the comments below because that is just what we do around here my friend. Hit that subscribe button and click the notification bell and as always my friend, go become the nurse that God created only you to be and I will see you over there in that next video.