How to Write Nursing Notes?

Answer

To write nursing notes, a nurse must follow the standard procedure used in the hospital of work. Standard nursing notes or sometimes called progress notes include the clinical status of a patient, usually recorded on a regularly timed intervals. A common format used for nursing notes is the SOAP or Subjective, Objective, Assessment and Plan.
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1. Document the patient's complaints or remarks as the "Subjective" aspect of the note, such as: Date, Time: 13:00. S: Patient reports abdominal incision pain of 6 of 10
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2 Additional Answers
To write nursing notes, be concise and impersonal. Write out medications and any symptom notes that might be mistaken for something else. Write only what you observe, not what you suspect.
Writing nursing notes can feel a little overwhelming at times because there are so many things to write. It's important to know what words you can abbreviate and what words you shouldn't abbreviate. Messing up on an abbreviation could cause trouble that you don't need. You can find more information at studentnurse.wetpaint.com
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