Emmanuel John Dela Cruz

BSN1A
Lesson 4: Activity 1 (Writing Basic Patient Notes)
1. As a future nurse, what are the informations that you need to write?
 Make sure your notes start with identifying information such the patient's name, age, and
date of birth, in addition to this, patient notes must be clear and concise. List the signs
and symptoms, their mental status, and their overall well-being.
2. How you should organize your notes?
 If you’re a beginner SOAP format is one of the best choices to list patient notes
Subjective (a family member's or friend's opinion) Objective (Assessment that you have
seen or that is reflected in reports from the lab or other medical sources) Assessment
(diagnosis) Plan (procedures to be done to address the diagnosis)

Patient Note
Subjective

Objective

Assessment

Plan

I realized that patient notes must be well organized and concise because this will serve as your
guide on how to treat your patient properly, It can also be your basis on what to do with several
cases.

I, as a nurse responsible in writing patient notes, should be careful on what to list in patient note,
because if you mislead patient note, there will be an error in nursing care and other nurses in
charge might misinterpret your patient notes.