Nursing, or SOAP, notes should cover subjective, objective, assessment and plan aspects of care. Subjective information consists of positive and negative information about a patient's history, past medical care, and symptom, family and social history review, states the University of Kansas Medical School. The objective portion includes a physical exam. The assessment is a synthesis of data from the patient's history and a probable diagnosis. The plan suggests specific treatments.Know More
SOAP notes must be timely and accurate, states AllNurses. Never document care before it is provided or include care provided by other staff. Complete all areas of the chart. Describe patients' pain only if there was an intervention. Only discuss the patient in question in the patient record. Record objective data, such as body temperature, rather than subjective descriptions, such as high fever, and do not refer to staffing issues or incident reports.
Nurse Together warns that it is easy to neglect records during the busiest times, such as during code warnings, transfers or when the nurse notices abnormal vital signs. Nursing notes must be legible, accurate, objective and free of grammatical and spelling errors or erasures. Do not perform charting in advance, and check institutional guidelines for the use of acronyms.Learn more about Business Communications
The website "What Should We Call Nursing" is a Tumblr blog site about common nursing experiences that are each paired with a GIF animation that describes or relates to the experience. It is one of many such websites based off the original "What Should We Call Me" Tumblr site and is written by a nurse working in the intensive care unit at a large teaching hospital in the United States.Full Answer >
You can find a free online guide for formatting an appellate brief, for both PC and Mac users, on the website of the University of Montana, notes the university. Its guide details step-by-step instructions on how to create a cover page, prepare the document and create a table of contents and a table of authorities.Full Answer >
Standard medical texts such as the Oxford Dictionary of Nursing and such websites as Nurseslabs.com and Quizlet.com provide information about the abbreviations, acronyms and other terms common to the nursing profession. The websites are accessible to laypeople wanting to understand more about their own medical reports and nursing students alike.Full Answer >
Nursing may be a good career for people who want to earn a living helping others in health care. However, the pressure, stress and work environment may be deterrents. The U.S. Bureau of Labor Statistics reported an above-average annual salary for registered nurses of $68,910 as of May 2013.Full Answer >