COMMUNICATION FOR NURSES:

WRITING BASIC PATIENT NOTES

 PATIENT
NOTES
• Initial notes: refer to the first or earliest assessment
• Interim or progress note: refer to the assessment reports
done in order to monitor the condition of the patient
• Discharge notes: are the reports given once medication is
discontinued or the patient is release from the hospital.
 SOAP formal is one way of organizing patient notes.
•Subjective (assessment given by the family member or patient
himself)
•Objective (assessment seen by you or reflected in laboratory or
•other medical reports)
•Assessment (diagnosis)
•Plan (procedures to be done to address the diagnosis
HOW NURSES SHOULD COMMUNICATE WITH
PATIENT?
For nurses, good communication in healthcare
means approaching every patient interaction with
the intention to understand the patient's concerns,
experiences, and opinions. This includes using
verbal and nonverbal communication skills,
along with active listening and patient teach-
back techniques.
10 NURSE COMMUNICATION SKILLS FOR
SUCCESS
1. Non-Verbal Communication
You can communicate a powerful message without saying
a word. Non-verbal nurse communication skills include
making eye contact and controlling the tone of your voice.
Appropriate body language, posture, and simply adding a
smile can go a long way in nurse communication with both
patients and colleagues.
2. Active Listening
Listen to understand; not solely to respond—this is one
of the best principles for active listening. When speaking
to a colleague or patient, lean forward and nod your head
to let them know you are engaged. Maintain eye contact.
Carry your body in a relaxed posture; do not cross your
arms
3. Personal Relationships
With practice, you can learn to show care, compassion,
and kindness while obtaining and providing information
to patients. You must be able to demonstrate a level of
interest in the collaborative relationship. This will help
the patient feel accepted and build their trust in you.
4. Inspire Trust
Always keep your word. Never make promises
you may not be able to keep. When you are with a
patient, be present. Listen to your patients and take
all their complaints or concerns seriously.
5. Show Compassion
Treat patients with respect and dignity. Being in the hospital
can be scary. Patients may feel depressed, helpless or even
frightened. Put yourself in the shoes of your patient. Doing so
will help you convey empathy while using your nurse
communication skills.
6. Cultural Awareness
Every patient is unique. They may come from different
countries, cultures or religions. Common practices and
gestures are not accepted by all cultures. Consider your
actions and strive for cultural awareness every time you
communicate with a patient.
7. Educating Patients
This nurse communication skill is at the heart of
nursing. You must be able to explain disease
processes, medications, and self-care techniques to
patients and their families.
8. Written Communication
This is essential for nurse-to-nurse communication.
Always ensure your written communication is concise
and easy to understand. Write in complete sentences that
are grammatically correct. Only use approved
abbreviations and terminology that is universal.
9. Presentation Skills
Nurses in leadership positions are not the only ones who
need this skill. You may be asked to present to nurses or
other staff members on a small or large scale. Plan your
message. Create pleasing visual aids that add value to the
presentation. Know your audience and understand what
they want from your presentation.
10. Verbal Communication
Verbal nurse communication skills are of the utmost
importance. Always consider your audience. Speak in
clear, complete sentences and consider your tone when
speaking. Nurse communication skills are indispensable
to your success as a nurse, and with practice, you can
become a nurse communication expert!
THE IMPORTANT DETAILS IN WRITING A
PATIENT NOTES

1. All relevant clinical findings.

2. A record of the decisions made and actions agreed as
well as the identity of who made the decisions and agreed
the actions.
3. A record of the information given to patients.
4. A record of any drugs prescribed or other investigations
or treatments performed.