When it comes to nurse’s notes most student nurses are up in arms on exactly what they should be writing. A focal note should be one of the easiest tasks to chart, but many students still find themselves struggling. There are different styles when it comes to writing nurses notes and you will eventually come to find a method that better suits your needs or department.
SOAP (ER) format is a common used style for nurse’s notes because they are easy to understand by all medical staff. The (ER) is also included but not always applied.
Subjective Data: This section of the nurse’s note should include a description of your patient based on what your patient has told you.
Example: Pain Assessment, Data that pertains to verbal statements that cannot be collected during a physical finding.
Objective Date: This section of the nurse’s note should include all your physical findings during your head to toe assessment or your focal assessments.
Example: Vital signs, Edema, wounds, etc.
Assessment; Including Nurses Diagnosis: This would be the nurse’s interpretation of your patients condition. Including your Nursing diagnosis based on the medical diagnosis the doctor has provided.
Plan: This will include the follow up you did based on your findings above.
Example: Treatments and Tests
Education: Any patient teaching would be explained here in your nurses notes, did you explain to your patient about their medications, use handouts, or give special instructions?
Return: Here you will include any follow up instructions or what your patient will need to look for based on their diagnosis.
DAR nursing notes are very commonly used for Focus Charting. They are simple and easy to follow.
Data: This area will include your subjective and objective information. In this area of your nurses note you will support the problem or describe any observations made at a specific time in your patients treatment.
Action: This area will include all actions you take to care for your patients. You will also include any type of evaluations or changes made to present care of your patient.
Response: Included in this area will be a description of your patients response to any of the care you have provided. As an example if you raised the head of bed because your patient has a complaint of shortness of breath you would chart this and also explain if your treatment was effective or ineffective. If your treatment was ineffective you would then chart any other treatments you tried and if the patient’s doctor was notified.
A nurse’s note is a legal document and should be treated in the outmost professional way. Your nurse’s note should be factual and not contain any sort of opinion. Always remember if you did not chart it, it did not happen. So always take credit for the work you do on any patient and make sure everything is charted.