Nursing tools

Care documentation

Note builder

Quick care note

No patient-identifiable information is stored by this page.

Documentation support tool only. Check, edit and verify before entering into the clinical record. Does not replace clinical judgement or local policy.

Patient state

Patient state details

Observations

Abnormal observations and action taken

Skin / pressure areas

Skin findings

Fluid intake / output

Fluid details

Pain

Pain details

Comfort, dignity and safety

Comfort/safety details

Nutrition and elimination

Nutrition/elimination details

Lines, tubes and devices

Device details

Discharge / Departure

Standard discharge

Self-discharge / Left before completion of assessment

Discharge plan Follow-up arrangements Additional advice given Other discharge information