Within the situation category the nurse will include the patient name, age and sex, as well as the chief complaint, date of onset, and pertinent diagnosis. Recent diagnostics and labs will be included in this section as well. The background section will include any significant history, which may include allergies, medication, treatments, or recent hospitalizations. The assessment category will include current signs and symptoms, and physical assessment data that is pertinent to the problem in concise statements. If the patient is experiencing pain, the nurse will complete a pain assessment, including the last time pain interventions were utilized. The final category will be used for treatment recommendations that the nurse deems clinically
