Nurses must communicate effectively both verbally and in writing. There are several types of patient notes nurses write, including initial notes, interim or progress notes, and discharge notes. The SOAP format is commonly used to organize patient notes, with sections for subjective findings, objective findings, assessment, and plan. Effective nurse communication includes skills like active listening, cultural awareness, educating patients, and inspiring trust. Proper documentation in patient notes ensures all relevant clinical information is recorded.
Nurses must communicate effectively both verbally and in writing. There are several types of patient notes nurses write, including initial notes, interim or progress notes, and discharge notes. The SOAP format is commonly used to organize patient notes, with sections for subjective findings, objective findings, assessment, and plan. Effective nurse communication includes skills like active listening, cultural awareness, educating patients, and inspiring trust. Proper documentation in patient notes ensures all relevant clinical information is recorded.
Nurses must communicate effectively both verbally and in writing. There are several types of patient notes nurses write, including initial notes, interim or progress notes, and discharge notes. The SOAP format is commonly used to organize patient notes, with sections for subjective findings, objective findings, assessment, and plan. Effective nurse communication includes skills like active listening, cultural awareness, educating patients, and inspiring trust. Proper documentation in patient notes ensures all relevant clinical information is recorded.
Nurses must communicate effectively both verbally and in writing. There are several types of patient notes nurses write, including initial notes, interim or progress notes, and discharge notes. The SOAP format is commonly used to organize patient notes, with sections for subjective findings, objective findings, assessment, and plan. Effective nurse communication includes skills like active listening, cultural awareness, educating patients, and inspiring trust. Proper documentation in patient notes ensures all relevant clinical information is recorded.
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COMMUNICATION FOR NURSES:
WRITING BASIC PATIENT NOTES
PATIENT NOTES • Initial notes: refer to the first or earliest assessment • Interim or progress note: refer to the assessment reports done in order to monitor the condition of the patient • Discharge notes: are the reports given once medication is discontinued or the patient is release from the hospital. SOAP formal is one way of organizing patient notes. •Subjective (assessment given by the family member or patient himself) •Objective (assessment seen by you or reflected in laboratory or •other medical reports) •Assessment (diagnosis) •Plan (procedures to be done to address the diagnosis HOW NURSES SHOULD COMMUNICATE WITH PATIENT? For nurses, good communication in healthcare means approaching every patient interaction with the intention to understand the patient's concerns, experiences, and opinions. This includes using verbal and nonverbal communication skills, along with active listening and patient teach- back techniques. 10 NURSE COMMUNICATION SKILLS FOR SUCCESS 1. Non-Verbal Communication You can communicate a powerful message without saying a word. Non-verbal nurse communication skills include making eye contact and controlling the tone of your voice. Appropriate body language, posture, and simply adding a smile can go a long way in nurse communication with both patients and colleagues. 2. Active Listening Listen to understand; not solely to respond—this is one of the best principles for active listening. When speaking to a colleague or patient, lean forward and nod your head to let them know you are engaged. Maintain eye contact. Carry your body in a relaxed posture; do not cross your arms 3. Personal Relationships With practice, you can learn to show care, compassion, and kindness while obtaining and providing information to patients. You must be able to demonstrate a level of interest in the collaborative relationship. This will help the patient feel accepted and build their trust in you. 4. Inspire Trust Always keep your word. Never make promises you may not be able to keep. When you are with a patient, be present. Listen to your patients and take all their complaints or concerns seriously. 5. Show Compassion Treat patients with respect and dignity. Being in the hospital can be scary. Patients may feel depressed, helpless or even frightened. Put yourself in the shoes of your patient. Doing so will help you convey empathy while using your nurse communication skills. 6. Cultural Awareness Every patient is unique. They may come from different countries, cultures or religions. Common practices and gestures are not accepted by all cultures. Consider your actions and strive for cultural awareness every time you communicate with a patient. 7. Educating Patients This nurse communication skill is at the heart of nursing. You must be able to explain disease processes, medications, and self-care techniques to patients and their families. 8. Written Communication This is essential for nurse-to-nurse communication. Always ensure your written communication is concise and easy to understand. Write in complete sentences that are grammatically correct. Only use approved abbreviations and terminology that is universal. 9. Presentation Skills Nurses in leadership positions are not the only ones who need this skill. You may be asked to present to nurses or other staff members on a small or large scale. Plan your message. Create pleasing visual aids that add value to the presentation. Know your audience and understand what they want from your presentation. 10. Verbal Communication Verbal nurse communication skills are of the utmost importance. Always consider your audience. Speak in clear, complete sentences and consider your tone when speaking. Nurse communication skills are indispensable to your success as a nurse, and with practice, you can become a nurse communication expert! THE IMPORTANT DETAILS IN WRITING A PATIENT NOTES
1. All relevant clinical findings.
2. A record of the decisions made and actions agreed as well as the identity of who made the decisions and agreed the actions. 3. A record of the information given to patients. 4. A record of any drugs prescribed or other investigations or treatments performed.