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2. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1][2] Documenting patient encounters in the medical record is an integral part of practice workflow ...

3. Nursing documentation - Wikipedia

   en.wikipedia.org/wiki/Nursing_documentation

   Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting ...

4. Notes on Nursing - Wikipedia

   en.wikipedia.org/wiki/Notes_on_Nursing

   Notes on Nursing: What it is and What it is Not is a book first published by Florence Nightingale in 1859. [1][2][3] A 76-page volume with 3 page appendix published by Harrison of Pall Mall, it was intended to give hints on nursing to those entrusted with the health of others. Florence Nightingale stressed that it was not meant to be a ...

5. Admission note - Wikipedia

   en.wikipedia.org/wiki/Admission_note

   Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care. Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes (SOAP ...

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7. OpenNotes - Wikipedia

   en.wikipedia.org/wiki/OpenNotes

   OpenNotes is a research initiative and international movement located at Beth Israel Deaconess Medical Center (affiliated with Harvard Medical School), that focuses on making health care more open and transparent by encouraging doctors, nurses, therapists, and other health care professionals to share clinical visit notes with patients, facilitating patients' legal right to access to their own ...