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As stated above your question is vague, but I think I know what you're getting at.
When I trained and first qualified in the UK (1980s) we had a "Kardex" which was just blank sheets. You free texted what you had done on a shift and noted significant events/outcomes.
Then they introduced care plans: a care plan with the patient's problems was written on admission (often not very well, often by a student nurse) and your documentation underneath had to be numbered, relating to the numbered problems. So if problem 1 was pain you would write : "1) complaining of pain in......."
Where I work now in France we have "transmissions ciblées" or targetted reporting, again based on problems. The sections in the computer are there for you to complete: "problem," "action," "outcome," again based on problems the nurses have identified.
Some hospitals have tick charts - vile.
I think the latter systems are infantile and often don't allow for you to document information that isn't necessarily linked to a problem.
I think such models have de-professionalised nursing. Lawyers or doctors for example don't document themselves with tick charts or by writing "Problem: Action:" etc. They simply write free text based on their professional knowledge and observation - like professionals. Nurses used to do that, and I'd be happy if we went back to that.
guest1154907
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What’s your favorite way to document