Hope this is the right spot.

I am a software engineer researching, for still another
EHR project, what exactly would be included in a nurse
note, lets say for a private practice doctor. My only
guidance so far is what my doctors asks me, issues,
medications, allergies, etc. I am trying to get answers
from actual folks that do the work rather than what
a physician believes to be done, or wants to be done.

If you were a nurse in a private practice office an a existing patient came in what would you document for the visit?

Thanks!