When it comes to nurse's notes most student nurses are up in arms on exactly what they should be writing. A focal note should be one of the easiest tasks to chart, but many students still find themselves struggling. There are different styles when it comes to writing nurses notes and you will eventually come to find a method that better suits your needs or department.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.
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