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 so far...

  3. Visit  Barbie10973 profile page
    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
    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
    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!!
    traumaRUs likes this.
  6. Visit  Teacher First profile page
    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?

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