Abdallah Adel

UH Educator
• promote good nursing care
• promote effective communication b/w nurses and, nurses, patients ,
professionals
Recording & Reporting
 SOAP Note.
• Subjective :
• Chief complaint • Plan :
• History of present medical illness • Diagnostic tests, drugs,
• Past Hx, family, social, review education, specific intervension
for needs, follow-up.
systems.
• Objective :
• Vital signs, general appearance,
abnormal findings from
assessment, facial exp and labs.
• Assessment :
• What are the differentials, global
assessment, decisions.
 20 Documentation Dos and Don’ts:
• Don’t erase what is recorded
• Record all relevant information
• Don’t write critical comments
• Don’t leave white space!
• Record in black or blue ink
• Clarify orders and treatment
• Chart your own nursing process
• Don’t use ambiguous statements
• Only use approved abbreviations
• Date/time/sign
• Write legibly
• Use ‘late entries’ notation
• Don’t write in anticipation
• Follow organisation policies
• Record telephone calls
• Complete action and outcomes
• Co-signing
• Use 24-hour clock
• Monitoring
• Confidentiality/Security.
 Nursing Report points to include
• Attending MD. • Skin.
• Consults. • Heart rhythm
• Diagnosis. • Lung status.
• Bowel status.
• Code status.
• Renal status.
• Allergies.
• Blood sugar
• Important Hx.
• Vital signs
• PCU/TELE/MED,SUR
• Procedures.
• Central lines.
• Labs.
• Feeding tubes.
• Family.
• Wound care.
• Isolation.
• Skin.
• Medications (PRN)
• Neuro status.
Bedside Report - As The Shift Changes....(FINAL)
 Remember …
not documented , not done
THANK YOU