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Objective ? Record what the nurse observes, hears, sees, and feels during the patient assessment. The types of assessments performed is dependent on the facility the patient is in (inpatient versus outpatient) and on the medical diagnoses and patient complaints.

Reporting is the verbal or written communication of data regarding the clients health status needs, treatments, outcomes and responses. Reporting facilitates clinical decision making, continuity of care and co-ordination among health team members.

Some examples of charting include documenting medications administered, vital signs, physical assessments, and interventions provided. Nursing notes are a narrative written summary of a given nursing care encounter. This might include a description of a nursing visit, a specific care event, or a summary of care.

How to Write Nurse Care Notes: A Cheat Sheet Date and time. Patient's name. Nurse's name. Clinical assessment, e.g., vital signs, pain levels, test results. Details of any incidents. Changes in behavior, well-being, or emotional state. Changes in the care provided. Instructions for further care.

Essential Elements of Nursing Documentation Evaluations. Clinical problems. Communication with other healthcare providers. Communication with and education of the patient, family, the individual designated as the patient's caregiver and other third parties. Medication records.

6 Tips for Taking Better Nursing Notes Standardized note-taking forms save time and effort. ... Take notes immediately, don't wait. ... Be wary of slang, jargon, and abbreviations. ... Only record facts and important events. ... Record any relevant observations and information. ... Date and sign all documents.

Progress note entries should not simply list tasks or events but provide information about what occurred, consider why and include details of the impact, outcome and plan for the patient and family.