Self-directed practice · do this outside class
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① Note from a vignette
② ISOBAR a patient
Task 1

Note from a vignette

Read the vignette, write a SOAP or DAR progress note, then self-check against the Skills Book Station 8 checklist below.

✓ Chest pain
✓ Medication refusal
✓ Patient fall
Clinical vignette

At 0930, Mr Leigh Brennan (68) presses his call bell with chest tightness — "It feels like a heavy weight on my chest." He is pale and diaphoretic. Obs: BP 148/92, HR 104, RR 22, SpO₂ 94% RA, pain 7/10. You sit him up, apply oxygen, obtain an ECG, and notify the MO (Dr Singh) at 0935, who attends at 0940 and orders troponin and aspirin.

During the afternoon medication round, Mrs Pauline Edwards (82) refuses her evening furosemide — "I don't want it, it makes me run to the toilet all night." She is alert and oriented. You explain the purpose and the risks of omission; she still declines. You notify the team leader and the MO is informed.

At 0600 you find Mr Dan Kovac (75) on the floor beside his bed — "I slipped getting up to the toilet." He denies hitting his head; no obvious deformity. Obs: BP 132/80, HR 88; no pain on movement except a grazed left elbow. You complete a neuro and limb assessment, assist him back to bed, and notify the MO and the in-charge.
SOAP — Subjective (their words) · Objective (measured) · Assessment (your judgement) · Plan.
DAR — Data (the focus) · Action (what you did) · Response (did it work?).

Write your note

Model note · for completeness, not exact wording
0930 — D: Reports chest tightness, "It feels like a heavy weight on my chest." Pale, diaphoretic. BP 148/92, HR 104, RR 22, SpO₂ 94% RA, pain 7/10. A: Sat upright, O₂ applied, 12-lead ECG obtained. Dr Singh (MO) notified 0935. R: Reviewed by MO 0940; troponin and aspirin ordered (see charts). Continuing cardiac monitoring. — [Name], RN
1715 — D: Declined evening furosemide, stating "I don't want it, it makes me run to the toilet all night." Alert and oriented. A: Explained purpose and risks of omission; patient verbalised understanding and continued to decline. Team leader and MO informed. R: Informed refusal documented; dose withheld; MO to review. — [Name], RN
0600 — D: Found on floor beside bed; states "I slipped getting up to the toilet." Denies head strike; grazed left elbow, no deformity. BP 132/80, HR 88, no pain on movement. A: Neurological and limb assessment completed — nil acute findings; assisted back to bed; MO and in-charge notified. R: For MO review and falls reassessment; neuro obs commenced. Incident form completed. — [Name], RN

Self-check · Skills Book Station 8

Tick each criterion your note satisfies. Satisfactory = all 14 met.

Assessment criteria
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Form and structure
✓Uses the approved progress note template or EMR field.
✓Dates and times every entry; uses the 24-hour clock.
✓Writes legibly; if paper-based, black ink; no white-out or obscured errors.
✓Corrects a paper error with a single strike-through, initials and date.
✓Signs each entry with full name, designation (RN), and registration where required.
Content and clinical reasoning
✓Records objective findings (observations, measurements, behaviours observed).
✓Records subjective data in the patient's own words, in quotation marks.
✓Documents nursing interventions performed and the patient's response.
✓Documents any escalation — the person notified, the time, and the outcome.
✓Uses a recognised structure (SOAP, DAR, ISOBAR) consistently.
Legal, ethical & professional standards
✓Maintains confidentiality and privacy (Privacy Act & NMBA Code).
✓Factual and contemporaneous; avoids subjective judgement or pejorative language.
✓Records consent, informed refusal, and advance care directive considerations.
✓Demonstrates awareness that the clinical record is a legal document.
✓ All 14 met — that's a Satisfactory note. Now try another vignette.
Task 2

ISOBAR a patient

Prepare a written ISOBAR handover for any patient, then time yourself delivering it aloud in under two minutes.

✓ Post-op (Khan)
✓ Cardiac (Romano)
✓ Respiratory (Lim)
✓ My own patient
Patient profile

Mrs Aisha Khan, 59, DOB 02/06/1966, MRN 410882. Day 1 post laparoscopic cholecystectomy. Stable, pain controlled, EWS 0. Nausea settled, mobilising. For discharge tomorrow if eating and drinking. No known allergies.

Mr Victor Romano, 77, DOB 19/11/1948, MRN 553410. Admitted with a CCF exacerbation. On IV frusemide, fluid restricted 1.2 L, O₂ 2 L (SpO₂ 94%), daily weights, EWS 2. Falls risk. Allergic to sulfa. Pending morning electrolytes.

Miss Grace Lim, 24, DOB 30/03/2002, MRN 661220. Admitted with an asthma exacerbation. On regular salbutamol nebs (weaning), SpO₂ 96% RA, EWS 1, peak flow improving. No allergies. For respiratory review in the morning.

Describe a patient you've cared for (de-identified — no real names or MRNs):
Deliver aloud — target under
2:00 minutes
{{ timer.display }} {{ timer.display }} Over two minutes — tighten it: lead with the risks, trim the background.

Write your ISOBAR

I
S
O
B
A
R

Before you call it done

Completeness check
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✓Two identifiers + receiver confirmed
✓All six ISOBAR letters covered, in order
✓Current observations + EWS, with the trend
✓Every outstanding risk stated explicitly
✓Responsibility transferred + invited questions
✓Delivered aloud in under two minutes