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To focus on the provision of safe patient care and to insure sufficient numbers of qualified nursing staff. One of the most important parts of a nurse’s job is accurate, descriptive documentation. Create documentation templates for the most common. Comprehensive note, basic soap note, annual wellness exam, well child check, acute uri, ortho focused, and.
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The information you put in a patient’s medical record should more or less track the nursing process. These forms have been developed from a variety of sources, including acp members, for use in your practice. Web the soapie charting method is a commonly used template for nursing notes that can be very helpful for any nurse. Most emrs have a template function.
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