For LPN / Charge Nurse (SNF)s ·
What you'll accomplish
By the end of this guide, you'll be able to use PatientNotes to generate properly structured SOAP-format nursing notes from brief descriptions of your clinical observations — directly on your phone, without needing to type a full clinical note from scratch.
What you'll need
What you should see: A simple note creation interface with options for note type (SOAP, DAP, nursing, etc.).
Troubleshooting: If patientnotes.app doesn't load, search for "PatientNotes app nursing notes" in your phone's browser — the URL may have changed since this guide was written.
This is where PatientNotes is different from a blank text field — you write in your own words, not in clinical format. Type what happened as if you were telling a colleague:
"Resident in Room 6 has been complaining of right hip pain since this morning. She rates it 6 out of 10. She's usually ambulatory with a walker but she's limping today and didn't want to get up. No visible swelling or bruising. I notified the charge nurse — that's me — and I'm documenting that I assessed her and am notifying the physician for possible x-ray."
Tap Generate (or the equivalent button). PatientNotes processes your description and outputs a structured nursing note with:
Review the output for accuracy. Edit any details that are incorrect before using.
Tap Copy to copy the full formatted note. Open PointClickCare, navigate to the resident's chart, and paste into the appropriate documentation field. Make any final edits and save.
Respiratory assessment: "Resident is [age] with [diagnoses]. Today I noticed [breathing changes, O2 sat, lung sounds]. [What I did/who I notified]."
Skin/wound observation: "I assessed a [wound type] on [location] for [resident]. Size: [measurements]. Appearance: [description]. Treatment: [what I applied]."
Behavioral change: "Resident with [diagnoses] was [behavioral description — restless, agitated, withdrawn] today — [different from or similar to baseline]. Vital signs [X]. [Any interventions or notifications]."
Post-fall assessment: "Resident found on floor by [who] at [time]. My assessment: [neuro check, vital signs, injuries found]. Physician notified at [time]. [Orders received]."
Routine shift note: "[Resident] is a [age] [diagnosis] resident. This shift: [what you assessed, vitals, anything notable or routine]. [Any concerns or interventions]."