Example Nursing Documentation

Example Nursing Documentation

Nursing documentation is one of the most important parts of nursing as it allows other nurses and physicians to understand what was done in a patient’s care. It also allows for continuity between shifts and lets everyone know if anything needs to be changed for a patient’s treatment plan. This section will explain the basics of nursing documentation so you can start practicing!

See the comments for how I was able to find a sample documentation.

Remember that all documentation needs to be objective, meaning there can’t be any opinions, assumptions, or judgments.

Remember that all documentation needs to be objective, meaning there can’t be any opinions, assumptions, or judgments. In other words, it’s important to avoid using words like “I think,” “I believe,” and so forth. Instead of saying “I think” when describing the patient’s treatment plan (and then going on to explain your rationale), use phrases like “the patient’s treatment plan was…” instead.

All entries in your SOAP notes will be about patient conditions. Anything other than that goes in the Progress notes.

The SOAP note is about what you did, and the Progress note is about what you want to do. The SOAP note focuses on patient conditions and progress. These are two different types of notes, so it’s important to know which one you’re writing at any given time.

The best way for me to explain these concepts is with an example: Let’s say a patient comes into the emergency room complaining of abdominal pain and nausea. You take their vital signs, perform some tests, order some X-rays (or whatever), write down all that info in your SOAP notes…then they leave with no diagnosis and go home feeling fine. So then what happens? That’s right—you’ll need another set of Progress notes!

In a SOAP note, write the Objective finding at the top of the section, followed by your Subjective finding (what you’re thinking about), Assessment, and Plan.

In a SOAP note, write the Objective finding at the top of the section, followed by your Subjective finding (what you’re thinking about), Assessment, and Plan.

  • Objective: An assessment of what is objectively true about a patient’s health situation or condition. Examples include: “Patient has type 2 diabetes,” “Patient has no symptoms of depression.” This section should be short—just one sentence long if possible—and it must be written in past tense because you’re describing an objective fact about this patient’s history.
  • Subjective: An assessment of how you think about a patient’s health situation or condition as it relates to their subjective experience (which means how they feel). This section helps you structure your thoughts and decide what tests should be ordered next; it may also include recommendations for follow-up care if necessary. Always use present tense when writing in this part—you’re describing something based on what happened recently with this person, not something that happened in the past per se!
  • Assessment: A description of any findings noted during your physical examination or evaluation process so far; these could include things like lab results, x-rays etcetera which help provide evidence supporting either positive or negative diagnoses made up until now (these would come under ‘Objectives’). For example if looking at bloodwork results shows signs indicating diabetes mellitus then they would go here instead!

The goal is for your documentation to look as if someone else could read it and be able to replicate what you did based on the information you gave.

Your documentation should be as clear and objective as possible. This makes it easier for other nurses to read your notes and understand what happened, why you did what you did, and how the patient’s condition changed over time.

For example, if a patient arrives with abdominal pain and vomiting, you might write: “Patient arrived with abdominal pain and vomiting.” That sentence alone is objective because it doesn’t state whether or not these are normal symptoms of this patient’s illness (which they could be). It also doesn’t make any conclusions about what caused the symptom–whether it was abdominal pain from a stomach bug or diarrhea from food poisoning–but it does tell us that yes indeed that was the patient’s status when we first saw him/her.

The goal here is for your documentation to look as if someone else could read it and be able to replicate what you did based on the information you gave them

Documentation is easy as long as you know why and how you’re doing it!

  • Documentation is a crucial part of the nursing process.
  • If you’re new to documentation, it can seem like a daunting task. But rest assured that it’s really not as hard as you might think! With some guidance and practice, you’ll be writing SOAP notes and progress notes in no time.
  • The following are some tools for writing documentation:
  • A SOAP note template. This lets you see the basic framework for how to write an excellent SOAP note. To download your free copy of our template, just click here!
  • A progress note template. This shows how to structure your progress notes so they’re concise and helpful for other nurses who will be reviewing them later on down the line when you’re gone from the patient’s bedside or clinic room (or wherever else). You can download this tool by clicking here!
  • Our discharge summary guide will tell you all about what goes into an effective discharge summary, including tips on how best to approach this important aspect of healthcare documentation without getting overwhelmed by its complexity (and length!). Click here if interested in downloading it now!

I hope this post has helped you to understand why we document things, how to write an SOAP note and what the differences are between them. It’s important to remember that when writing up your notes, all of these things need to be done in a way that makes sense to other people who may read them later on down the road (whether it be another nurse or doctor). Good luck!

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