Nursing notes are the documents that are created by nurses or health care professionals and are based on detail information of a patient. Almost in all hospitals nurses are directed to write nursing notes for their patients on a daily basis that is admitted in the hospitals. Nursing notes are usually based on information like the health issue, test report, progress on a daily basis, diagnosis, medicines and a medical plan that is based on the thoughts of a nurse or doctor. There are a number of formats available for writing a nursing note however, the most common and standard format is known as SOAP or Subjective Objective Assessment Plan. As the name implies, the nursing note written in a SOAP format is based on subjective data like the feelings that your patient is told to you, objective data like physical findings of the patient during head to toe assessment like wounds, edema and blood pressure etc, assessment section of the nursing note is based on the diagnosing made by nurse and the diagnosis that are provided by the doctor and the final section known as plan is based on the future follow up on the basis of the diagnosis.
A Sample Nursing Note
The test denies the use of any illegal drug. Last urine 8/12/2003 was positive for cocaine, which patient adamantly denies using.
Although he agrees that going to a support group is a good idea, he has actually attended only once in the past month.
Liver enzymes slightly elevated on lab of 9/8/2012. The patient seems more irritable, although when this is pointed out to the patient, his response was “now don’t you start on me too.”
The patient has likely relapsed to cocaine use
Increase urine testing to twice weekly
Get patient to accept referral to an intensive outpatient treatment program as a condition of continuing Subutex.
Guidelines for writing a nursing Note
- On the top of the nursing note sheet, write the name of the patient and the date.
- If you are writing a nursing note in SOAP format, write “S” or subjective data as a heading and proceed. For writing subjective data it is important to talk with your patient, ask how he/she is feeling today, ask whether his/her feelings are good as compared to previous day and some other such types of questions.
- Write all the information under the heading of subjective data with reference to previous days as this will help you and the doctor in understanding the difference and progress of the patient.
- Then write the heading of objective data or simply “O” and list all the physical findings and their condition in it. Check the blood pressure of the patient, check the wounds and write a note on the basis of previous day note in order to clear the progress.
- Write “A” or assessment as a heading and list the results of nursing diagnoses like any medical test such as a urine test, blood test X-rays etc as well as list the changes that you find in the condition of the patient.
- Write plan or “P” and write the names of the medicines or therapies that you think should administer to the patient. This section is of great importance and a nurse should try to write it with great acre.