Several structured formats are commonly used in nursing, including:
SOAP Notes: SOAP stands for Subjective, Objective, Assessment, and Plan. This format helps in organizing patient information systematically. SBAR: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a communication tool used to convey critical information quickly and effectively. Flow Sheets: These are used to document routine care activities and vital signs over time, providing a visual representation of a patient's progress. Care Plans: These comprehensive documents outline the nursing interventions and expected outcomes for individual patients.
