I know nursing notes have been mentioned before, but....

Nurses General Nursing

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...I am seeking a definition of old school documentation of nursing notes. After searching the threads I cannot see exactly what I am looking for. I know there are many formats for documentation but the one I would like defined by somebody who knows, is constructed as the one that generally begins with:

Mentation: ie - Pt alert and orientated

Observations: ie - Obs within normal limits (or not, etc)

Input / Output.................................................gaps...............................................

......finishing with possible plans for discharge of patient / Nil issues pt.

Is anybody able to provide a sequence that fills in the gaps? Ahem, I'm aware of what needs to go in the gaps - its just I'd like it defined by somebody who is very knowledgable in this area. Any help is greatly appreciated.

I'm not sure that what you think you want exists as a codified entity. Many of us charted with a top-to-bottom review of systems-- pt's subjective stmts if any, neuro, psychosocial, special senses, cardiovasc, resp, GI, GU/repro, ortho, skin, activity, with labs/vs/diagnostic imaging findings/consults where they fit in, and plan. Is that what you meant? Or are you looking for a historical artifact for some sort of paper? Florence's classic "Nursing: What it is and what it is not" might have what you seek. Help us out here.

Some hospitals have a system which everyone follows (in Sydney, Australia). Some places everybody has their own system for writing notes. The notes format I want has been demonstrated by a few nurses I have had contact with. It's specific......it's set out in a certain way. It's not the top to bottom method.

The format that was nicely written out for me has unfortunately been lost. Personally, I blame the wife :)

I can't tell you exactly how it is but I'll know when I see it.

It begins mentation, observations, in/out then something something something in a specific order. Agh!

Its like trying to find the grail now.

Specializes in Trauma, Teaching.

Are you thinking of SOAP notes?

Subjective data, Objective, Assessments and Plans

Specializes in Med/Surg,Cardiac.

In addition to the assessment which is separate from notes in my facility, I always write a note specific to diagnosis. If they came in with chest pain, I'll write "pt c/o cp x1. Relieved with 1 nitro per order, see MAR. BP 144/82. HR 90 NSR. RR 18 even and unflavored, patient denies shortness of breath. S1S2 heart sounds noted. Pedal pulses 2+...." the most important thing to me is to paint a picture of relevant findings. If bowel sounds fro. I 2 days ago are needed, I'll refer to previously charted assessments. I only note about data that isn't in an assessment or that I want the doc to know.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

Specializes in Home Health/PD.
In addition to the assessment which is separate from notes in my facility, I always write a note specific to diagnosis. If they came in with chest pain, I'll write "pt c/o cp x1. Relieved with 1 nitro per order, see MAR. BP 144/82. HR 90 NSR. RR 18 even and unflavored, patient denies shortness of breath. S1S2 heart sounds noted. Pedal pulses 2+...." the most important thing to me is to paint a picture of relevant findings. If bowel sounds fro. I 2 days ago are needed, I'll refer to previously charted assessments. I only note about data that isn't in an assessment or that I want the doc to know.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

"Unflavored" respirations! Lol. Gotta love the typos

No, not SOAPIE.

Specializes in Med/Surg,Cardiac.

"Unflavored" respirations! Lol. Gotta love the typos

Hahaha! Predictive text will be the death of me.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

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