(3) Assessment ("A") entries document the writer's analysis of the patient's
problem (the writer's evaluation of what he observed).
(4) Planning ("P") entries document the plan of action to be taken to resolve
the patient's problems.
b. Admitting Entry. When the Nursing Notes is initiated on a patient newly
admitted to the MTF, the first entry documents certain admitting information. This initial
admitting entry usually includes the date and time of admission, the manner in which the
patient arrived (ambulatory, wheelchair, litter, and so forth), any wounds (including
sores and decubitus ulcers) present, any prostheses (dentures, artificial limbs, and so
forth), reason for admission, TPR (temperature, pulse, and respiration) and BP upon
admittance, height, weight, known allergies (usually obtained from patient), patient's
level of consciousness (LOC), and any medications and/or treatments which the patient
is taking. An admitting entry in SOAP format is shown in figure 1-16.
c. Discharge Note. When a patient is transferred or discharged, a final entry is
made in the patient's Nursing Notes. The entry usually includes the date and time the
patient was discharged (or transferred), the manner in which the patient left
(ambulatory, wheelchair, or stretcher), the name of the person or persons (parents,
ward personnel, and so forth) who accompanied the patient, any medications or
schedules given to the patient, discharge information and instructions given the patient,
and a note of any follow-up visits to be made. When appropriate, the entry should
contain a statement indicating the patient acknowledges and understands all
instructions (for example, "Patient states he has a good understanding of all discharge
Treat the information contained on the forms in the patient's chart, including
Nursing Notes, as confidential. Do not discuss the patient's chart with another patient,
within hearing range of patients, or in the presence of unauthorized personnel. Record
information away from the patient and do not let the patient see or hear what you record
since the patient may misunderstand the information or become unduly upset. If a
patient asks medical questions or asks about information on his chart, refer the patient
to the physician or nurse who can best answer his questions. Do not make entries in
the patient's chart for someone else. Do not have someone else chart your entries.