Write your assessment. In the assessment, you discuss the patient's problem and the findings you obtain from a physical examination. Include data both objective and subjective, but keep both kinds separate. Objective data is numerical and things you can hear, feel and see, such as vital signs, breath sounds or the feel of the patient's skin. Subjective data involves general feelings, like when the patient says "I just can't keep anything down." Make sure you refrain from your own theories about what is going on. For instance, if the patient is experiencing chest pain, do not say "I think the patient is having a myocardial infarction" because there are many reasons why someone's chest might hurt. Your assessment should be presented in a systematic manner, organized from head to toe. Do not leave any body system out because that suggests you did not examine that area.
Describe your interventions. The response is where you describe what actions you took based on the data you obtained from your assessment. Leave nothing out. Remember, if it was not documented, it was not done. Include any necessary conversations with other healthcare providers, especially the doctor. Include with whom you consulted, what you told them and what their responses were. If medication was given, list the drug name, the dose size, and the method and time of administration. Other actions, such as "patient repositioned on her right side" or "patient returned to bed," must be listed as well. Include any diagnostic tests arising from your assessment as well.
Evaluate your actions. The evaluation lists the effectiveness of your interventions by describing the patient's response to them. As in the preceding steps, list everything that happened. Be very specific, and watch your word choice. Avoid statements like "We failed to convert the patient to a normal cardiac rhythm." In this example, it tells a person reading the chart that you did not even attempt to defibrillate someone who was in cardiac arrest. Instead, say something like "Six shocks total delivered via defibrillator; patient remained in ventricular fibrillation." Do not worry if something did not work. Every patient is different. Besides, you are not the sole member of the healthcare team. The important thing is to show you recognized a need for intervention and took appropriate action. If a problem still remains, you can start the whole process over again.