SOAP (ER) format is a common used style for nurse's notes because they are easy to understand by all

medical staff. The (ER) is also included but not always applied. Subjective Data: This section of the nurse's note should include a description of your patient based on what your patient has told you. Example: Pain Assessment, Data that pertains to verbal statements that cannot be collected during a physical finding. Objective Date: This section of the nurse's note should include all your physical findings during your head to toe assessment or your focal assessments. Example: Vital signs, Edema, wounds, etc. Assessment; Including Nurses Diagnosis: This would be the nurse's interpretation of your patients condition. Including your Nursing diagnosis based on the medical diagnosis the doctor has provided. Plan: This will include the follow up you did based on your findings above. Example: Treatments and Tests Education: Any patient teaching would be explained here in your nurses notes, did you explain to your patient about their medications, use hand-outs, or give special instructions? Return: Here you will include any follow up instructions or what your patient will need to look for based on their diagnosis. DAR nursing notes are very commonly used for Focus Charting. They are simple and easy to follow. Data: This area will include your subjective and objective information. In this area of your nurses note you will support the problem or describe any observations made at a specific time in your patients treatment. Action: This area will include all actions you take to care for your patients. You will also include any type of evaluations or changes made to present care of your patient.

Response: Included in this area will be a description of your patients response to any of the care you have provided. As an example if you raised the head of bed because your patient has a complaint of shortness of