What are the Common Types of Nursing Documentation?
Several types of documentation are commonly used in nursing practice:
Flow Sheets: Used to record routine assessments and interventions, such as vital signs. Narrative Notes: Detailed, chronological accounts of patient care and interactions. Electronic Health Records (EHRs): Digital systems that consolidate patient information and facilitate easy access and sharing among healthcare providers. SOAP Notes: A structured format for documentation that includes Subjective data, Objective data, Assessment, and Plan. Care Plans: Documents outlining the individualized plan of care for each patient. Incident Reports: Used to document any unusual events or errors that occur during patient care.
