How to Write Narrative Charting
Narrative charting is a means of recording patient data that enables doctors and nurses to consult a patient's status and plan future treatment quickly and effectively. Successful nursing students must become proficient using both the DAIR and SOAIP methods of narrative charting. Each letter in the acronym DAIR represents a step in the information-gathering and treatment procedures: Data, Assessment, Intervention and Response. Likewise, each letter in SOAIP stands for a type of data or action: Subjective, Observation, Assess, Intervene and Propose. The key to proficient narrative charting is to practice making and recording observations, drawing reasonable conclusions and formulating the best plan of action based on those conclusions.
Gather empirical evidence based on your five senses and established facts. Record the data you know to be true in the "D" category.
Use the "A" section to write an assessment of the data and draw conclusions based on your experience and knowledge as a nurse.
Intervene to provide assistance as needed and record the action you take to treat the patient in the "I" area of the narrative charting.
Record the patient's response to your intervention and treatment under the "R" heading.
Ask the patient to describe the event that caused the injury or the symptoms of an illness and record these under the "S" category for subjective information gathered.
Gather empirical evidence based on your five senses and established facts. Record how the patient looks and sounds as they describe the situation during the subjective step and any other observations you make and record them under the "O" heading for objective information.
Assess the data in the "A" section and draw conclusions based on your experience and knowledge as a nurse.
Intervene to provide assistance as needed and record the action you take to treat the patient, including the names and amounts of any medication administered, in the "I" area of the narrative charting.
Propose additional steps that may be required at a future point to provide continued relief, such as administering another dose of medication after the required amount of time passes. Record your recommendations in the "P" category.
- "Charting Made Incredibly Easy"; Lippincott, Williams and Wilkins; 2010
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