• Reviews the terminology for written communications with physicians and staff.
• Describe the types of documentation, including SOAP notes and DART charts.
• Details the documentation of history taking, including medical, social, and family history, physical assessments, and systems.
• Covers the documentation of nursing skills and procedures as well as medication administration.
• Addresses the documentation required in specialized fields such as OB/GYN, pediatrics, psychiatric, and outpatient nursing.
• Includes how-tos for template, electronic, and other forms of charting.