Nursing Documentation - Page 5

Hi can anyone help with a progress note for a skin tear, this is my first wound assessment. really not sure how to start it off

I recently came across this list of charting examples for a head to toe assessment and it nearly made me weep with joy. It's a really good set of charting examples that will be handy, especially the first semester of nursing school.

http://www.bergen.edu/faculty/wguari..._examples.html

You can also expand on the SOAP format by making it a SOAPIER note. subjective, objective, assessment, plan, intervention, evaluation, reeval if needed.
And DAR-data, action, response keeps you organized.

I've always preferred soapier notes.

Hi, I'm new to this website and I think it's a great place for info. Can someone give me a little help with my nursing diagnosis. A little background first. Patient is having a bowel resection within the next few days and has an active infection (pneumonia), she is also anemic and her religious belief forbids blood products. So I think the most important diagnosis would be Risk for shock but it's the related to part that always gets me, mine seem to never be good enough for my instructor I can't include the surgery because she hasn't gone through it yet, but what about risk for shock related to active infection and low RBC count secondary to anemia? Any thoughts? Thanks in advance.

Sorry this question is in the wrong forum :0