Jose Rizal University & Medical Center

Nurse’s Note Form

Patient Name: Hospital Case No.:

Date of Birth: Attending Physician/Consultant:

Admitting Diagnosis: Ward/Room/Bed No.:

Date/Shift Nurse’s Notes

Focus:
 Hypertension; non-compliance to therapeutic regimen

Data:
 Patient is diagnosed with hypertension
 Has stopped taking maintenance medication
 High BP
 Occasional headache
 Mild chest pain
 Does not adhere to healthy diet (like to eat fatty foods)

Action:
 Educate the patient on the importance of complying with the therapeutic
regimen.
 Refer to a nutritionist to develop healthy meal plan for hypertensive patient.
 Encourage active lifestyle such as engaging in exercise activities.

Response:
 Patient has verbalized that she understood the importance of complying with the
therapeutic regimen and has committed to follow the therapeutic regimen
prescribed by the doctor such as maintenance medications.
 Patient has agreed to consult with a nutritionist and has set an appointment for
planning healthy meal plan.
 Patient committed to engaging healthy lifestyle by expressing desire in enrolling in
Zumba class.
A. Sample of Narrative Charting
B. Focus Charting

C. SOAPIE/R