Skilled Nursing Notes Pdf
What Are Nursing Notes and When Are They Used?
Nursing notes contain all medical information, filed by nurses. In particular, they cover changes in the patient's health and medicine while undergoing medical treatment and procedures in the hospital. These details are very important since they help to better analyze treatment results and improve care, make additional prescriptions or cancel unneeded ones. The document is used by the healthcare team, doctor, nurse, and in some cases by lawyers, judges or juries.
Who Should File Nursing Notes?
Providing a correct, complete and accurate report of the patientэs healthcare and status timeline is the responsibility of the nurse. Those templates may vary from hospital to hospital, but the information they contain is almost the same.
In particular, skilled nursing notes cover:
Nursing notes are kept together with all doctor's examination information, blood pressure and sugar results, allergic reactions, and prescriptions and make a full pack of individual's health state. It is very important to keep careful track of all changes in the state of the person, as every nurse and doctor are responsible for human health and life.