Documentation Reference


Hi everyone,

I will be graduating soon as an FNP, however, I am looking for a good book reference for documentation (SOAP notes, H & P) I have Bates, but I'm looking for others. I am finding that performing the exam is not difficult, but charting everything is where I have my issues. I'm getting better with practice, but I would love a good reference tool.


ETA: As a nurse, computer charting has destroyed me....all those click boxes are great, but having to write narrative notes has me all "tied" up :)


1 Post


Hello. I am glad to see your question. I too have same dilema. Having concrete essential set of tools helps. Patient load per shift be it 10 or 15 is challenging, and brevity and accuracy are necessary if you want to leave work at work, and keep billing/QC, and Med Director out of your charts. Please anyone with any info is welcome. Another important point is "BILLING". How to survive this monster?

Nursing Rocks!