There are several common formatting standards used in nursing documentation, including:
SOAP Notes: Stands for Subjective, Objective, Assessment, and Plan. This method organizes information systematically. PIE Notes: Stands for Problem, Intervention, and Evaluation. This format focuses on the patient’s problems and the interventions applied. Charting by Exception (CBE): Only records significant findings or deviations from the norm. Narrative Notes: A free-text format that allows nurses to describe patient conditions and care in their own words.
