Several systems are used for nursing documentation:
Electronic Health Records (EHR): Digital records that provide comprehensive and integrated patient information accessible to authorized healthcare providers. SOAP Notes: A method of documentation that stands for Subjective, Objective, Assessment, and Plan, commonly used for recording patient progress. PIE Charting: Focuses on documenting Problems, Interventions, and Evaluations. Focus Charting: Centers on documenting data, action, and response related to specific patient issues.
