How Do Nurses Document Physical Examination Findings?
Accurate documentation is critical: 1. SOAP Notes: Using the Subjective, Objective, Assessment, and Plan (SOAP) format to organize findings. 2. Electronic Health Records (EHR): Entering data into EHR systems for easy access and sharing among healthcare providers. 3. Narrative Notes: Writing detailed descriptions of findings and observations. 4. Flow Sheets: Utilizing charts and graphs to track vital signs and other measurable data over time.
