Republic of the Philippines

EASTERN VISAYAS STATE

UNIVERSITY
Burauen, Leyte
EDUCATION DEPARTMENT
_______________________________________________________________________________
Course Gen. Ed. 002 Semester 1ST
Code
Course BEED 1-A Academic 2022-
Title Year 2023
Lesson 6.1 Communication for Nurses: Reporter Group 6
Writing Basic Patient Notes No.

Topic Overview
The students will know the importance of effective communication in
nursing. They will also know what a patient note is and the purpose of it.
Students will learn how to organized details from informants. And lastly, they
will learn how to write a basic patient notes correctly and accurately.

Topic (Discussion)

COMMUNICATION IN NURSING: WRITING BASIC PATIENT NOTES

Communication in Nursing defines as exchanging information,

thoughts, and feelings among people using speech or other means. The
patient conveys their fears and concerns to their nurse to help them make a
correct diagnosis. Thus, the benefits of nurses being able to communicate
effectively are overwhelmingly critical.

I. Important Communication Skills in Nursing

1. Be Flexible
2. Learn to Listen
3. Do not make assumptions
4. Understand cultural differences
5. Read body language
6. Strengthen writing skills

II. Importance of Effective Communication in Nursing

1. Good communication in healthcare means approaching every patient
interaction with the intention to understand the patient's concerns,
experiences, and opinions.
2. Having good communication skills is essential to collaborating on
teams with your fellow nurses and colleagues from other disciplines.
It’s also important to patient-centered care.
3. Nurses learn about their patients' needs, concerns and health issues
through communication, which involves active listening. Making this
effort to communicate with patients impacts the accuracy of diagnoses
and the quality of care.
 4. Strong verbal and written communication skills are central to
improving health outcomes, fostering relationships with co-workers,
patients and families, and navigating complex situations.

III. What is a Patient Notes?

Patient Notes -is the primary communication tool to other clinicians
treating the patient, and a statement of the quality of care. This record the
assessment of the patient’s condition before, during, and after the treatment.
Hence, patient note can be classified as initial notes, interim or progress
notes, and discharge notes.

1. INITIAL NOTES refer to the first or earliest assessment

2. INTERIM NOTES refer to the assessment reports done in order to
monitor the condition
3. DISCHARGE NOTES are reports given once a medication is discontinued
or the par from the hospital.

IV. Purpose of Writing a Patient Note

1. The note is your tool to communicate with yourself on future visits and
other providers who may care for the patient. Most importantly when
you're writing patient notes: keep your audience in mind, that's the other
members of the patient's care team, and in many cases the patient
themselves.

2. To provide continuity of care, which means documenting services so

others have a source upon which to base care.

3. It reduces the risk of treatment errors and improves the likelihood of a

positive outcome.

V. What to be included in writing basic patient notes

The basics of clinical documentation,
1. Date, time and sign every entry.
1.1 Although simple, its importance cannot be overstated. The timing
of events and reviews is often crucial in piecing together
information about deteriorating patients.

2. Write your name and role as a heading and the names and roles of
all others present at the encounter.

3. Make entries immediately or as soon as possible after care is given.

3.1 Prompt documentation reduces the risk of you forgetting key details.
3.2 It ensures all other team members are aware of any changes to a
patient’s condition or management plan. In reality, this isn’t always
possible.

4. Be legible.
4.1 There’s no point documenting well if no one can decipher it.
 5. Be thorough, accurate, and objective.

6. Maintain a professional tone.

6.1 Sarcasm, attempted joking or a casual tone may reflect badly on you.

7. Only use approved abbreviations.

7.1 It is better to use no abbreviations at all to avoid confusion.

8. Addenda.
8.1 If an addendum is made, this should also be verbally
communicated to other teams and nursing staff.
8.2 Sign off any addenda with the time and your full details.

9. Mistakes.
9.1 If a mistake is made, correct it with a single strikethrough.
9.2 Follow that by clearly signing and dating the correction.

VI. Format of Writing a Patient Note

The SOAP Method
SOAP – stands for Subjective, Objective, Assessment, Plan
-one way of organizing patients notes
- it’s a useful acronym for remembering the main elements of any
clinical note.

1. Subjective- (assessment given by the family member or patient himself)

1.1 This section describes the patient’s current condition in a narrative form.
Include the patient’s chief complaints, including onset, chronology, quality,
and severity.

1.2 It is important to document what the patient tells you about how they are
feeling, in their own words. Use quotations if appropriate, using quotation
marks.

2. Objective- (assessment seen by you or reflected in laboratory or other

medical reports)
2.1 Here, you should document objective, repeatable and measurable facts
about the patient’s status.

2.2 You may include objective observations about how the patient appears
from the end of the bed. For example, “Patient appears pale and in
discomfort.”

2.3 In this section, also include observations and vital signs.

2.4 Findings from a physical examination. For example, “Widespread

expiratory wheeze on auscultation of the chest.”
2.5 If relevant, also include laboratory results, fluid balance, and other
measurements. (E.g. urine, IV fluids, NG feeds, drain outputs, age/weight)

3. Assessment- (diagnosis)
3.1 Summarize the salient points and the primary medical diagnosis in this
section. If the diagnosis has already been made, comment on whether the
patient is clinically improving or deteriorating. For example, “Impression:
Resolving community-acquired pneumonia.

3.2 A complete list of all diagnoses and issues should ideally be completed in
this section every 1-2 days, or whenever a new issue arises. This is extremely
useful, especially for after-hours staff who may need to rapidly assess a
deteriorating patient.

4. Plan- (procedures to be done to address the diagnosis)

4.1 Document a clear plan, including further investigations, referrals
procedures, and new medications to be charted.

4.2 If possible, include an estimated discharge date. This is immensely

beneficial information for your Nursing Unit Manager to plan for the week
ahead.

Example SOAP Template:

Image Source: https://safetyculture.com/checklists/soap-note-template/ Image Source: https://www.pinterest.com/pin/435301120216595306/

Definition of Terms
1. Communication - the imparting or exchanging of information or news.
2. Healthcare -efforts made to maintain or restore physical, mental, or
emotional well-being especially by trained and licensed professionals —
usually hyphenated when use attributively health-care providers.
 3. Patient - a person receiving or registered to receive medical treatment.
4. Nurses - a person trained to care for the sick or infirm, especially in a
hospital.
5. Patient-centered - care is about treating a person receiving healthcare
with dignity and respect and involving them in all decisions about their
health.
6. Colleague - a person with whom one works in a profession or business.
7. Medication - treatment using drugs.
8. Medical - relating to the science of medicine, or to the treatment of
illness and injuries.
9. Treatment - medical care given to a patient for an illness or injury.
10. Prognosis - the likely course of a disease or ailment.
11. Reimbursement - the action of repaying a person who has spent or
lost money.
12. Diagnosis - the identification of the nature of an illness or other
problem by examination of the symptoms.
13. Laboratory - a room or building equipped for scientific experiments,
research, or teaching, or for the manufacture of drugs or chemicals.
14. Adenda - is an addition required to be made to a document by its
author subsequent to its printing or publication.
15. Retrospect - a survey or review of a past course of events or period of
time.
16. Documentation - material that provides official information or
evidence or that serve as a record.
17. Abbreviations - a shortened form of a word or phrase.
18. Clinical - relating to the observation and treatment of actual patients
rather than theoretical or laboratory studies.
19. Care - the provision of what is necessary for the health, welfare,
maintenance, and protection of someone or something.
20. Notes - a brief record of facts, topics, or thoughts, written down as an
aid to memory.

Learning Activities
Activity 1
Direction: Using a graphic organizer, illustrate the concepts of patient
notes.

Activity 2
Direction: Give what is ask and answer effectively.

Material
1. Tarpapel

References.
1. https://onthewards.org/how-to-document-well/
2. https://languages.oup.com/google-dictionary-en
3. https://tigerconnect.com/blog/six-ways-nurse-communication-improves-deliver-healthcare/
4. https://academicpartnerships.uta.edu/articles/healthcare/importance-of-communication-in-
nursing.aspx
5. https://online.uhv.edu/articles/rnbsn/communication-in-nursing.aspx#:~:text=As%20frontline
%20workers%20in%20healthcare,families%2C%20and%20navigating%20complex%20situations.