Communication for Nurses: Writing Basic Patient Notes

Chapter 4, lesson 1 Module

I. Introduction

There are times when you are presented with a plethora of

information and you find yourself having difficulty recalling them all. What
strategies must you do to be able to systematically store and recall this
information. As an educator, it is very important to know how to take an organized
Basic Patient Notes.

In this lesson, you will learn about the significance of communication

in nursing and how to gather details of information to take patients notes correctly
and accurately.

II. Objectives

At the end of this lesson, learners should be able to:

a. Organize details gathered from informants

b. Follow instructions in taking Basic Patients Notes
c. Write patient Notes correctly and accurately

III. Strategies

A. Activity
Direction: Observe the following pictures and answer the following
questions.
 1. What do you observe from the picture?
2. What can you say about the photos?
B. Analysis
After the activity we have done:
a. From the activity, what do you think our topic is all about?
b. Do you think the activity is related to our topic?
c. What have you observed from the activity?
C. Abstract

COMMUNICATION FOR NURSES:

WRITING BASIC PATIENT NOTES

WHY ARE WE WRITING NOTES WHEN WE SEE A PATIENT?

It’s really important to think about the purposes of writing

basic patient notes because that’s going to help us understand why
we do things in a way do when we’re writing it. One of the main
reasons we write notes is so that we can actually document the
information and later on we can go back and look at those notes
and see what we did, what we’ve heard from the patients. We are
 tracking what we’re doing and have source of truth around
anything.

WHAT ARE PATIENT’S NOTES?

Patient notes is the record the assessment of the patient’s

condition before, during and after the treatment. This note can be
classified as initial notes, Interim or progress notes and discharge
notes.
Initial notes refer to the first or earliest assessment, Interim
or progress note refer to the assessment reports done in order to
monitor the condition of the patient, and discharge notes are
reports given once medication is discontinued or the patients is
released from the hospital.

Figure 1. example of patient notes

 HOW DO YOU ACTUALLY WRITE A PATIENT NOTES?

1. CHECK to make sure you got the right patient

2. HEADING is what your note is all about. Ex. Surgery Progress
note
3. Make sure date and time are correct
4. Who you are should be clearly identified

SOAP format is one way of organizing patient notes:

Subjective (assessment given by the family member or patient

himself)

Objective (assessment seen by you or reflected in laboratory or

other medical reports)

Assessment (diagnosis)

Plan (procedures to be done to address the diagnosis)

D. Application
We’re going to have an activity entitled “LET’S GRAPH!”. Group of
students were given 5 minutes to make their artistic graph containing the
SOAP format. After 5 minutes the group will do the sound of the animal
they want to portray.

IV. Evaluation

Direction: Answer the following:

1. What have you realized after the discussion?

2. What should you do as a responsible nurse in terms of writing basic
patient notes?
3. Do you think writing notes are important?
V. Reflection

In this lesson I’ve learned how to take basic patient notes and realized
that writing basic patient notes is very important to the treatment that a medical
doctor or any health practitioner would offer so they can have accurate
medication for the patients and be organized in terms of finding the problem of a
patient.

At first, I don’t understand why do we have to study about this topic

because this topic says that it is for the communication of nurses when we are
teachers. However, later on I’ve realized that we as a future educators can
encounter different plethora of circumstances and so we should be able to have
knowledge about it, because there is a saying that a teacher is a friend, family,
leader and a doctor of students.

Prepared by: Jamilla, Patricia A.

BSED MT 1-1