Documenting patient care

Documenting Patient Care
Name
Institution Affiliation
Nursing narrative note
Patient name: Nancy Jackson
Age: 9 years
Gender: female
Medication Period: between 8th May and 13th May 2018.
The notable changes: the patient experiences slow growth since she looks like 6 months old baby yet she is 9 years. The other changes are the increase in the feeding tube of the child that resulted in the new feeding formula. And also there is an increase in weight of the patient from 48 to 50 pounds. The patient was also diagnosed using NANDA-I.
The narrative format entails the name of the patient, age, gender among other basic information about the patient (“Sample Nursing Notes Template”, 2018). It also contains the medical history of the patient including the latest changes that were made in the diagnosis of the patient (Kluwer, 2018). The SOAP entails the data obtained from the family of the patient, the gathered information, assessment data and the plan that nurses have for the patient. SOAPIE and SOAPIER format include the intervention that taken by the nurse to come up with an expected goal (Kluwer, 2018). The evaluation of the intervention’s effectiveness and also looking into any changes that need to be made in the intervention. They are written after a day whenever there are unsolved problems. PIE contains the problems that need to be solved, the intervention that the nurse put in place to solve the problem and the evaluation of the effectiveness of the intervention used.
The use of the electronic health record would be more effective in the treatment of the patient since it would contain the required information about the patient.

And also it would display the medical attention that has been used on the patient in the previous medications that has been done to her. Therefore the nurses would not use trial and error when carrying out the diagnosis.
References
Kluwer, W. (2018). Using SOAP, SOAPIE, and SOAPIER formats: Nursing2018. Retrieved from https://journals.lww.com/nursing/Citation/1999/09000/Using_SOAP,_SOAPIE,_and_SOAPIER_formats_.28.aspx
Sample Nursing Notes Template – 7+ Free Documents Download in PDF. (2018). Retrieved from https://www.sampletemplates.com/business-templates/nursing-note-template.html