Progress notes/ Clinical file

We chart both in a SPEADO format (skin, pain, elimination, activity, diet and other) and to the FIM - therefore, a basic nursing note, including addressing abnormals, and include specifics regarding the FIM support (although we're trying to revamp to document elsewhere for the FIM) - we are an acute rehab unit and chart differently from the rest of the units in the hospital. Some nurses write almost in an outline format, others prefer a narrative note. It was hammered into us in school to chart short and sweet, include only what you needed - then I started in rehab and learned to be a bit more elaborative in my charting. Hope that helps!