yx5001

T Thank you for your comments. It helps so much ? I believe that learning the writing skill from other nurses' notes is a better way for improvement.

Thank you for your reply. Mandrian. IDK when I learned english

Thank you. In this case, the patient's baseline is hypertension. How should I mention the VS stable and highlight the BP appropriately in DAR chart?

As a non-English speaker, I definitely have a hard time writing progress notes and reports. I usually give my instructor a confusing to read them because of inappropriate words using. I found some sample sentences and words to write nursing notes and reports. However, it is not enough. I'm wondering if somewhere I can learn the sentences and words describing normal and abnormal statements of patients, such as respiratory system, mobility or psychosocial. To indicate how worse my writing skill is, I posted two examples of writing I just made. patient 1: Dx - dementia; time - morning Data: Received patient in bed. Asleep. Woke up when name called. Oriented by name only. Raised HOB 30 degrees to take VS. VS stable with BP 170/70. Denied pain when asked. Morning care done by HCA. No BM. Fed 30% breakfast and tolerating well. Action: Strictly monitor and record I/O fluid as per doctor's order. --------------yx5001 patient 2: Dx - hip fracture; time - morning Data: Received patient in bed. Asleep. Easy to aroused. Oriented by three. Observed a severe non-productive cough. Denied pain when asked. Assisted HCA to do morning care and transfer the patient to wheelchair. -------------------------------------yx5001 Action: Assessed for lungs and found fine crackle sounds at right low base. Had a teaching of deep breathing and coughing technique by graphic because of language barrier. ----------------------------------------------------------------------------yx5001 Respons: No more coughing after being transferred to wheelchair. Thank you for any feedback and suggestion