SOC, ROC, recert nurses note, Template

[OutandaboutRN]

Hey guys,

Just wondering if anyone has and wants to share a template that they use for writing the nursing note. Seems like it takes me forever to write and am curious if anyone has a template or system that organizes the thought process making the notes more uniform and easier to complete. Please please share!

[Isabelle49]

Have had templates in the past, but they are too cookie cutter like. My note explains what I see, hear, feel, smell and do and how the patient tolerates the visit. I also include any teaching that I do. The SOC note is extensive, as it is a lot like a history and physical you might see prepared by a doc. The SOC, Recert and ROC notes incorporate as much information as I can, sort of like a history and physical that tells the story of what has been happening with the patient; when read by anyone, they have all the information needed in a 'nutshell'. Think of the SOC, Recert and ROC note as a written report you might have to leave for someone. Your routine visit notes cover what you observed and did during the visit an how the patient tolerated/responded to it.