How to write narrative charts

How to write narrative charts

Narrative charts are a way to record patient data. This allows nurses and doctors to quickly consult patients and plan for future treatment. Nursing students who are successful will be able to use both the SOAIP and DAIR 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. Each letter in SOAIP represents a type or data: Subjective, Assessment, Assess, Intervene, Propose, and Observation. To be proficient at narrative charting, you must practice making observations and drawing reasonable conclusions. Then, formulate the best plan of actions based on these conclusions.

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DAIR Charting

Step 1

You can gather empirical evidence using your five senses as well as established facts. Keep track of the facts you believe to be true under the "D" category.

Step 2

You can use the "A" section of the form to assess the data and draw conclusions using your knowledge and experience as a nurse.

Step 3

Assist the patient if necessary and note the actions you took in the "I" section of the narrative charting.

Step 4

Under the heading "R", record the patient's reaction to your intervention.

SOAIP Charting

Step 1

Ask the patient for details about the incident that led to the injury or symptoms of the illness. Record these under the "S” category to gather subjective information.

Step 2

You will gather empirical evidence using your five senses and other established facts. Take notes of the patient's appearance and sound during the subjective step. Also, note any additional observations and keep them under the heading "O" for objective information.

Step 3

Analyse the data in "A" and draw conclusions based upon your knowledge and experience as a nurse.

Step 4

Assist the patient if necessary and note the actions taken in the "I" section of the narrative charting.

Step 5

You may suggest additional measures that could be needed in the future to provide relief. For example, you might consider administering another dose after the prescribed time. Your recommendations should be recorded in the "P” category.