Documentation Notes

Question 1

Narrative

Answer 1

Information provided in written sentences or phrases;usually time sequenced

Question 2

SOAP

Answer 2

Subjective data
Objective data
Assessment
Planning

Question 3

PIE

Answer 3

Problem
Intervention
Evaluation

Question 4

Focus

Answer 4

Data
Action
Response

Question 5

CBE

Answer 5

Charting by exception
Standards met, sign or check off; stands not met—write narrative or SOAP note