template or course for documentation template or course for documentation | allnurses

template or course for documentation

  1. 0 i am an fnp student who wishes to improve my documentation for both h&p as well as problem focused notes. i feel like this is often overlooked by preceptors etc and i want to make sure i am doing "best practice". i can't seem to find anything out there to guide me so i am hoping some of you may have suggestions.

    many thanks,

  2. 4 Comments

  3. Visit  Barbie10973 profile page
    #1 0
    I've been looking for the same thing for years! If someone knows of one I'd love to know!!
  4. Visit  traumaRUs profile page
    #2 0
    Maxwell's - it comes as PDA/iphone format as well as in print. I use the print version - its a small, wire-bound book and has H&P, discharge notes, soap notes, problem focused notes - everything.
  5. Visit  Barbie10973 profile page
    #3 1
    Very good reminder...I have a Maxwell's...but I'm looking for some example's of write up's I suppose, to try to improve mine. Happy Nurse's Day btw!!
  6. Visit  Teacher First profile page
    #4 0
    try typing in things like "sample h&p notes" into a search engine, and see what comes up. i found the following pretty quick: http://www.emr4physicians.com/pdf/urologynote42.pdf http://www.usuhs.mil/icm/writtenh&psample07-08.pdf
    also look for patient case studies, and practice writing note following accepted guidelines.
    by the way, i had to write up several major h&p assignments every semester i was in school, don't you have to do that?