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How to Write an Effective Nursing Note: A Comprehensive Guide
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Taking nursing notes is a regular practice in patient care. But writing nurses notes can be hard to know where to start, or how to make your notes stand out from the rest of your peers.
You want to be able to capture all the information you need in as few words as possible, but you also don’t want to leave out any important details.
Writing nursing notes, like building effective nursing care plans , is one of the core responsibilities of being a nurse, and learning how to write them effectively and quickly will set you up for success in your future career.
The most effective nursing notes include terminology, observance, detail, and readability. Whether you’re in clinicals or on the job, it’s important to understand why and how they’re crucial to providing quality care.
We’ll show you what goes into nursing notes and how to write them effectively for the best patient care.
But first, let’s get into how they’re relevant to charting.
The Basics of Nurse Notes
A nursing note is a detailed record that captures the comprehensive care provided by nurses. It includes the nurse’s observations, assessments, nursing diagnoses , care plans, interventions , and evaluations of patient outcomes ( ADPIE ).
Nurse notes are a key part of patient care documentation. They track the progress of a patient’s condition over time and facilitate communication between healthcare providers.
Accurate and thorough nursing notes are essential for delivering high-quality care and maintaining legal and regulatory compliance.
The Role of Nursing Notes in Documentation and Charting
Nursing students learn charting (along with notes) early and often to better paint a picture of the patient’s health at the time of the visit or for the duration of the time. Charting includes the notes made by nurses and put into a computer.
Charting information is purely objective (IV site documentation, alarms, test results, etc.), and this nursing documentation is set up specifically for each working medical facility.
Making quick notes when evaluating the patient will enable you to chart more quickly and provide more accurate nurses’ notes immediately.
Read here to learn how notes and charts fit into the nursing process .
How Are Nurses’ Notes Used?
The first thing to know about nursing notes is that they’re not just for patients but also for nurses. Nurses notes fill documentation gaps between doctors, patients, and other providers.
The primary purpose of a nursing note is to track the progress of the patient’s condition over time.
You also may share notes with other team members, depending on their role within the department. This allows them to adjust treatments accordingly if necessary (e.g., increasing dosage).
How to Write Effective Nursing Notes
To write effective nursing notes, follow these guidelines:
- Verify the Correct Patient’s Chart: Ensure you are documenting in the correct patient’s record.
- Tell the Patient’s Story: Use your notes to provide a clear and comprehensive narrative of the patient’s condition and care.
- Document Real-Time Observations: Take notes in real-time or as soon as possible to ensure accuracy.
- Use Complete Phrases: Avoid abbreviations that could lead to misinterpretation.
- Document Safety Checks: Include any safety measures in place to protect the patient.
- Use Standard Acronyms: Familiarize yourself with common acronyms like SOAPIE (Subjective, Objective, Assessment, Plan, Intervention, Evaluation) and DAR (Data, Action, Response).
In short, you write everything you observe as a nurse and any significant medical information. Nursing notes include information about how the patient feels, what they need, and what’s going on with their health in a short, detailed summary.
When you put every piece of information together, make sure that everyone who needs to know about a patient’s care can access that information quickly and easily.
What To Write in a Nursing Note?
The information included in a nurses note varies depending on the facility’s needs and the type of care being provided. Nurses notes are often filled with abbreviations and medical jargon – which you and staff will know, but the patient most likely won’t.
Generally, here’s what you can expect from your nurse’s notes:
- General patient information: name, gender, age, address.
- Reason for their visit & Chief complaint: What they came in for and how long they’ve been under your care.
- Observations: What you’ve observed during your time with them (what they look like when they’re awake or asleep, their breathing patterns and heart rate, etc.).
- Treatment plan : A care plan layout based on the collection, analysis, and organization of nurses’ clinical data.
- History: Patient history including present and past ailments.
- Medication(s): Any medications given to the patient (including dosage details ), along with medication history.
- Ending summary: An overall evaluation of their condition at the time of discharge.
Ideally, you should take brief notes while you’re in the same room as the patient, and add more detail as soon as you leave the patient’s room while the information is still current and fresh in your mind.
Nursing Notes Examples
The following are four nursing notes examples varying between times of a patient’s admittance:
Acute Pancreatitis Nursing Note (Example)
Patient Name and Age: Kane Schneider, 33
Date: May 14th, 2022
Chief Complaint: The patient’s chief complaint is acute pancreatitis, which they developed after eating a large amount of greasy food. The patient also reports that they have been experiencing nausea and vomiting since they arrived at the hospital.
Diagnosis: Acute Pancreatitis
History: The patient reports that they have had similar symptoms in the past and have had several episodes of acute pancreatitis over the past few years. The patient has had all of their gallbladders removed in attempts to treat this condition.
The patient has not been taking any medication for nausea, but has been receiving IV fluids for hydration due to their vomiting.
Physical exam: Vital signs are stable — pulse = 72 beats per minute, respirations = 16 breaths per minute, temperature = 98.2 degrees Fahrenheit (F). Physical examination reveals a pale and diaphoretic person in moderate distress with abdominal tenderness on palpation in the epigastric area.
No jaundice or bruising is present on examination of the skin or mucous membranes. Abdominal distention is present with peripheral edema noted around the umbilicus area as well.
Urinary Tract Infection Nursing Note (Example)
Patient Name and Age: Elaina Hassan, 77
Date: January 29th, 2022
Chief Complaint: She has been experiencing fever, chills, and dysuria for two days.
History of Present Illness: Patient has previously experienced mild hypertension and heart failure.
Physical exam: Vitals – The patient’s temperature is 99 degrees Fahrenheit. The pulse is 100 beats per minute and regular. The blood pressure is 140/90 mm Hg.
Diagnosis: Urinary tract infection .
Assessment: She appears to be in moderate distress and is slightly tachycardic at 104 beats per minute. Patient demonstrates evidence of right lower quadrant tenderness on palpation as well as suprapubic tenderness on deep palpation. The patient’s urine dipstick test reveals 1+ blood and no white blood cells or nitrites present in her urine sample.
Evaluation: She has been treated with antibiotics and fluids, and can now urinate without discomfort.
Alcohol Withdrawal Nursing Note (Example)
Patient Name and Age: Willie Brandt, 41
Date: March 21st, 2022
Diagnosis: Alcohol withdrawal
Assessment: Patient was brought in by his family for alcohol withdrawal. When they brought him in, he was experiencing tremors, hallucinations, and confusion.
History: Patient has been drinking alcohol for 24 years, and his family noticed that he started to drink more heavily over the past few years.
Plan of care: Monitor vital signs every 15 minutes; check urine output every hour; administer IV fluids as ordered; administer medication as ordered (e.g., benzodiazepines); monitor electrolytes every 6 hours or as ordered; provide emotional support to patient and family; educate patient on how to avoid future episodes.
Upper Respiratory Infection Nursing Note (Example)
Patient name and Age: Jazmin Adkins, 25
Diagnosis: Upper respiratory infection, including rhinitis and pharyngitis.
Assessment: Patient presented with symptoms of a cold, including runny nose, sore throat, cough, and congestion. Symptoms have persisted for 2 weeks.
History: Patient works as a bartender at a local restaurant. Two evenings per week she works late into the night and does not get enough sleep; she also drinks alcohol on these nights (about 4 drinks).
She washes her hands frequently at work but does not use hand sanitizer before touching his face or putting his hands in his mouth. Patient often smokes cigarettes outside work hours and is always around cigarette smoke when out with friends or family members who smoke regularly.
General Tips for Writing Nurse Notes
When writing a nurse note, you must first think about what is important for the patient. But it’s also important to ask yourself: what’s important for the rest of your team?
Here are some simple tips for writing the perfect nursing note:
- Stay on point and be specific .
- Use shorter sentences when possible for easier reading.
- Include interdisciplinary team members .
- Use bullet points when possible (it’s much easier to scan through a list than long paragraphs).
- Sign each entry of your note with your name and credentials .
- Use correct grammar and spelling (and avoid autocorrect).
- Add new information throughout the patient’s visit .
- List a patient’s most important condition and its severity level (for patients with multiple conditions).
- Don’t forget the smaller details .
Include patients’ room and bed numbers at the top of the page (if you’re writing a note for an inpatient).
Take Your Nursing Learning to the Next Level
Taking nurses notes will be one of many, many job responsibilities you’ll have. You’ll be better prepared for success in your future work if you can write them efficiently, promptly, and with the maximum amount of detail.
You’ll have great nursing notes when you can quickly balance medical terminology, writing skills, detail, and observation.
To get all of that down easier and more efficiently, you’ll need a supplemental nursing school resource . SimpleNursing offers just about everything you need (study guides, question banks , assessments, and more) to perfect your nursing process.
Get the most out of your nursing courses and effectively put them together in your studies.
Unlock these resources with a free trial today and check out our NCLEX prep course as you prepare for your nursing exams .
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Education: Associate Degree in Nursing, Cerritos Nursing School Master of Science in Nursing, Capella University | Specialization: Nursing Education
5 Perfect Nursing Progress Notes Examples + How to Write
If you are a nurse, you know one of the most important parts of our jobs is to document about our patient’s status, the care they receive, and their response to any treatments. There are many types of documentation nurses and other healthcare professionals use. One type of documentation is a nursing progress note. If you are new to nursing or unsure about the different types of documentation, you may wonder, “What is a nursing progress note?” In this article, I will tell you about nursing progress notes, what they are, their purpose, and the advantages and disadvantages of using them. I will also share 5 perfect nursing progress notes examples + how to write them. At the end of this article, I will answer some frequently asked questions about nursing progress notes to give you more insight into these important documents.
What is a Nursing Progress Note?
What is the purpose of writing a nursing progress note, is a nursing progress note the same as a nursing progress chart, 3 advantages of nursing progress notes, advantage #1: nursing progress notes keep patient information accessible, advantage #2: you can use nursing progress notes to promote positive patient outcomes, advantage #3: nursing progress notes create a legal record of the care you provide, 2 disadvantages of nursing progress notes, disadvantage #1: it is time-consuming to create nursing progress notes, disadvantage #2: it is easy for the nursing progress note to become repetitious, what elements should be included in a nursing progress note, 1. subjective data:, 2. objective data:, 3. nursing assessment findings:, 4. planned nursing interventions:, 5. patient response to interventions:, what elements should not be included in a nursing progress note, 1. jargon or meaningless phrases should not be included:, 2. avoid providing unnecessary information:, 3. another nurse’s opinion or statement about a patient:, 4. unapproved medical abbreviations should be avoided:, 5. care not yet given should never be documented:, how to write a perfect nursing progress note, step #1: begin the nursing progress note with relevant information, step #2: provide a general description of the patient and the reason for their visit/encounter, step #3: perform a patient interview to obtain subjective information, step #4: gather essential objective data and record your findings., step #5: describe proposed treatment plan, step #6: document nursing interventions, step #7: document the patient’s response to care or treatment provided, what are the perfect examples of nursing progress notes, bonus 7 most common mistakes to avoid while writing nursing progress notes, mistake #1: adding irrelevant or unnecessary information, about the mistake:, how to avoid:, mistake #2: making assumptions, mistake #3: using incorrect or unapproved abbreviations, mistake #4: writing sloppy notes, mistake #5: waiting too long to write your note & forgetting important facts, mistake #6: not reviewing progress notes from previous shifts, mistake #7: not documenting care or interventions, my final thoughts, frequently asked questions answered by our expert, 1. who can write a nursing progress note, 2. when to write a nursing progress note, 3. do nurses write progress notes every shift, 4. ideally, how long should nursing progress notes be, 5. what’s the most important part of a nursing progress note, 6. what are the 5 legal requirements of nursing progress notes.
• Documentation must be centered around the nursing assessment and nursing interventions that should occur. • The note should document previous conditions and responses to treatments as well as changes in the patient’s health condition and any new interventions to be implemented. • The nursing progress note must reflect the extent of care needed, such as continuous care, the patient’s needs, and any interventions initiated to provide that care. • HIPPA Privacy Rules must always be upheld. • The nursing progress note must be clear, legible, and contain accurate information.
7. Can I Use Abbreviations In A Nursing Progress Note?
8. what tense do i write a nursing progress note, 9. are nursing progress notes handwritten or printed, 10. how to sign off nursing progress notes, 11. what happens if i forget to write a progress note on the time it should have been written, 12. can a nursing student write a nursing progress note.
Nursing Notes and Study Guides for Nurses
Welcome to our extensive and detailed collection of nursing notes and study guides , meticulously designed to cater to students and medical, nursing, and healthcare professionals. This list of nurse notes is a vital resource, encompassing various topics, ranging from the intricacies of human anatomy and physiology to the nuances of various diagnostic and laboratory tests. It’s your treasure trove of knowledge, indispensable for anyone aiming to excel in their nursing career.
Table of Contents
Anatomy and physiology, diagnostic and laboratory tests, nursing fundamentals, infectious diseases, maternal and child health nursing, pediatric nursing, medical-surgical nursing.
- Mental Health and Psychiatric Nursing
Nursing Pharmacology
Nursing theory.
Our list of nurse notes begins with an in-depth exploration of human anatomy and physiology, covering every major system in the body, such as the cardiovascular, digestive, endocrine, and nervous systems. Special attention is given to both the male and female reproductive systems, providing a comprehensive understanding of these complex areas.
- Cardiovascular
- Female Reproductive
- Integumentary
- Male Reproductive
- Respiratory
- Special Senses
This section on diagnostic and laboratory tests is particularly valuable for those involved in clinical settings. It includes detailed guides on critical procedures like bronchoscopies, CT scans, echocardiograms, and mammography . Additionally, there’s a vital reference on normal lab values, a must-read for healthcare professionals to accurately interpret diagnostic results.
- MUST READ: Complete Normal Lab Values Reference Guide & Cheat Sheet
- Bronchoscopy
- Chest X-ray (Chest Radiography)
- Colonoscopy
- Computed Tomography (CT) Scan
- Echocardiogram
- Fecal Analysis (Stool Analysis)
- Holter Monitoring
- Lumbar Puncture (Spinal Tap)
- Magnetic Resonance Imaging (MRI)
- Mammography (Mammogram)
- Pap Smear (Papanicolaou Smear)
In the realm of nursing fundamentals, our collection of study guides is unparalleled. It includes practical advice and tips on documentation, the nursing process , and patient education . This section delves into everyday nursing procedures, offering step-by-step guides on various patient care strategies, from arterial blood gas analysis to urinary catheterization , ensuring a well-rounded understanding of nursing responsibilities.
- 50+ Tips & Techniques on IV Insertion
- 501 Nursing Bullets: Fundamentals of Nursing Reviewer
- Administering Oxygen Therapy
- ADPIE: A Guide to Understanding Nursing Process
- Arterial Blood Gas Analysis Made Easy with Tic-Tac-Toe Method
- Bag Technique in Nursing
- Bed Bath and Hygiene Care
- Blood Pressure Measurement
- Blood Transfusion Therapy and Transfusion Reactions
- Change a Hospital Gown for Patients with IV Line
- Cleaning Bedpans and Urinals
- Collecting Stool Specimen
- Collecting Urine Specimen
- Colostomy Irrigation
- Common Drugs and Their Antidotes Cheat Sheet
- Communication in Nursing: Documentation and Reporting
- Cranial Nerves Assessment Chart and Cheat Sheet
- Documentation and Reporting in Nursing
- Ear Irrigation
- Eye Drop Instillation
- Focus Charting (F-DAR): How to do Focus Charting or F-DAR
- Hair Care and Combing
- Hand Hygiene and Handwashing
- Head-to-Toe Assessment: Complete Physical Assessment Guide
- History of Nursing in the Philippines
- Hospital Diets: Guide and Cheat Sheet
- Hot Sitz Bath (Hip Bath)
- Inhaled Medications Administration
- Intramuscular Administration
- Intravenous (IV) Therapy Technique
- Intravenous Administration
- IV Fluids and Solutions Guide & Cheat Sheet
- Managing Peripheral IV Therapy Complications
- Measuring Central Venous Pressure (CVP)
- Moving Patients from Bed to Chair or Wheelchair
- Nail Care and Hygiene
- Nasogastric Intubation
- Nursing Abbreviations and Acronyms: Guide to Medical Terminology
- Nursing Care of the Dead (Postmortem Care)
- Nursing Management: Guide to Organizing, Staffing, Scheduling, Directing and Delegating
- Oral Care and Hygiene
- Oral Medication Administration
- Patient Positioning: Complete Guide and Cheat Sheet for Nurses
- Providing Back Care and Massage
- Providing Evening Care (PM Care) to Patients
- Subcutaneous Administration
- The 10 Rights of Drug Administration
- The Nightingale Pledge And Its Versions
- The Nursing Process: A Comprehensive Guide
- Thoracentesis
- Total Parenteral Nutrition (TPN)
- Tracheostomy
- Transdermal Patches and Medications
- Urinary Catheterization
- Vaginal Irrigation (Douche)
- Wound Care: Cleaning and Dressing Wounds
For those focusing on infectious diseases, our guide covers a comprehensive range of conditions from Anthrax to Zika Virus. This segment provides essential information for the effective management and understanding of these diseases, crucial for healthcare professionals dealing with infectious diseases.
- Chikungunya Virus
- Coronavirus Disease 2019 (COVID-19)
- Cytomegalovirus
- Ebola Virus Disease (EVD)
- Hand, Foot, and Mouth Disease (HFMD)
- Infection Control in Nursing
- Meningococcemia
- Methicillin-resistant Staphylococcus Aureus (MRSA)
- Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
- Pertussis (Whooping Cough)
- Polio (Poliomyelitis)
- Salmonella Infection (Salmonellosis)
- Typhoid Fever
Our Maternal and Child Health Nursing notes provide a concise yet comprehensive overview of maternal, newborn , and child healthcare. Covering pregnancy, childbirth, postpartum , and newborn care , this guide addresses high-risk pregnancies, fetal development , and common complications. It also includes critical maternal health concerns and essential aspects of pediatric care, ensuring a holistic understanding of this specialized nursing area.
- Abruptio Placentae
- Breastfeeding
- Care of the Newborn
- Cesarean Birth
- Ectopic Pregnancy
- Family Planning/Contraceptive Methods
- Female Reproductive System Anatomy and Physiology
- Fetal Development & Fetal Growth Assessment
- Gestational Trophoblastic Disease
- GTPAL: Guide to Gravidity and Parity in Obstetrics
- Pregnant Adolescent
- Pregnant Woman Over the Age of 40
- Pregnant Woman with Physical and Mental Challenges
- Pregnant Woman who is Substance Dependent
- Musculoskeletal Disorders in a Pregnant Woman
- Cancer and Pregnancy
- Mental Illness and Pregnancy
- Trauma in Pregnancy
- Respiratory Disorders in a Pregnant Woman
- Endocrine Disorders in a Pregnant Woman
- Neurological Disorders in a Pregnant Woman
- Gastrointestinal Diseases in a Pregnant Woman
- Hematologic Disorders in a Pregnant Woman
- Sudden Pregnancy Complications
- Anomalies of the Placenta
- Incompetent Cervix
- Labor and Labor Complications
- Newborn Reflexes
- Placenta Previa
- Postpartum Care and Changes
- Postpartum Depression
- Postpartum Hemorrhage
- Pregnancy Changes and The First Prenatal Visit
- Pregnancy Induced Hypertension
- Subfertility
- The Menstrual Cycle and Menstrual Disorders
- The Newborn & Normal Developmental Milestones
- VEAL CHOP Nursing Mnemonic
- 360 Nursing Bullets: Maternity and Newborn Nursing Reviewer
Our Pediatric Nursing notes offer a comprehensive guide on the care and management of infants to adolescents. Covering a range of topics from common illnesses like chickenpox to complex conditions such as juvenile diabetes , this resource provides key insights into pediatric assessments, development stages, and vaccinations. It also includes tailored nursing care plans for various pediatric disorders, equipping nurses with the knowledge to deliver age-appropriate care effectively.
- Acute Glomerulonephritis
- Acute Nasopharyngitis
- Allergic Rhinitis
- Attention Deficit Hyperactivity Disorder
- Cerebral Palsy
- Chicken Pox (Varicella)
- Cleft Lip and Cleft Palate
- Congenital Hypothyroidism
- Congenital Talipes Equinovarus (Clubfoot)
- Croup Syndrome
- Cryptorchidism (Undescended Testes)
- Cystic Fibrosis
- Diabetes Mellitus Type 1 (Juvenile Diabetes)
- Down Syndrome (Trisomy 21)
- Enterobiasis
- Epiglottitis
- Febrile Seizure
- Galactosemia
- Gastroenteritis
- Gastroesophageal Reflux
- Hirschsprung Disease (Aganglionic Megacolon)
- Hydrocephalus
- Hypospadias and Epispadias
- Idiopathic Thrombocytopenic Purpura
- Imperforate Anus
- Intussusception
- Iron Deficiency Anemia
- Juvenile Rheumatoid Arthritis
- Kawasaki Disease
- Lead Poisoning
- Measles (Rubeola)
- Nephrotic Syndrome
- Non-Organic Failure to Thrive
- Otitis Media
- Pediatric Dosage Calculations
- Pediatric Health and Physical Assessment
- Phenylketonuria
- Pyloric Stenosis
- Respiratory Syncytial Virus
- Reye’s Syndrome
- Rheumatic Fever
- Roundworms (Ascariasis)
- School Phobia
- Seizure Disorders (Epilepsy)
- Spina Bifida
- Sudden Infant Death Syndrome (SIDS)
- Thalassemia
- Tonsillitis and Adenoiditis
- Tracheoesophageal Atresia
- Turner Syndrome
- Wilms Tumor (Nephroblastoma)
In this guide for Medical-Surgical Nursing includes a comprehensive guide covering a wide range of conditions needing medical and surgical management. It provides detailed insights into diseases like diabetes , hypertension , heart failure , and cancer , along with information on surgical procedures and postoperative care. Ideal for nurses in hospital settings, this resource offers essential knowledge on preoperative and postoperative management, patient education , and handling complex health conditions.
- Acetaminophen Overdose
- Achilles Tendonitis
- Acoustic Neuroma
- Acute Lymphocytic Leukemia
- Acute Renal Failure
- Acute Respiratory Distress Syndrome (ARDS)
- Anaphylactic Shock
- Appendicitis
- Bacterial Meningitis
- Bell’s Palsy
- Benign Prostatic Hyperplasia
- Bile Duct Stones (Choledocholithiasis)
- Brain Abscess
- Bronchiectasis
- Buerger’s Disease
- Burn Injury
- Cardiogenic Shock
- Cerebrovascular Accident (Stroke)
- Chest Pain (Angina Pectoris)
- Cholecystitis
- Chronic Obstructive Pulmonary Disease (COPD)
- Chronic Renal Failure
- Contact Dermatitis
- Cushing’s Syndrome
- Deep Vein Thrombosis
- Dengue Hemorrhagic Fever
- Diabetes Mellitus
- EKG Interpretation & Heart Arrhythmias Cheat Sheet
- Fluid and Electrolytes, Acid-Base Balance
- Heart Failure
- Hepatic Cirrhosis
- Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS)
- Hypertension
- Hypothyroidism
- Hypovolemic Shock
- Intracranial Aneurysm
- Intraoperative Phase
- Legionnaire’s Disease
- Metabolic Acidosis
- Metabolic Alkalosis
- Myocardial Infarction
- Neurogenic Shock
- Osteoarthritis
- Osteogenesis Imperfecta
- Osteoporosis
- Pancreatitis
- Patent Ductus Arteriosus
- Peptic Ulcer Disease
- Peritonitis
- Pneumothorax
- Postoperative Phase
- Preoperative Phase
- Pulmonary Embolism
- Pulmonary Tuberculosis
- Respiratory Acidosis
- Respiratory Alkalosis
- Rheumatoid Arthritis
- Sepsis and Septic Shock
- Sickle Cell Anemia
- Status Asthmaticus
- Urinary Tract Infection
- Urolithiasis (Renal Calculi)
- 160 Nursing Bullets: Medical-Surgical Nursing Reviewer
In this section, you’ll find Mental Health and Psychiatric Nursing notes that provide a detailed guide on assessing, diagnosing , and treating mental health disorders. Covering a spectrum of conditions from depression to substance abuse , the guide delves into various therapeutic techniques, medication management, and patient care strategies. It also emphasizes the crucial role of psychiatric nurses in offering support, education, and advocacy to patients and their families, underscoring a comprehensive approach to mental healthcare.
- Amnestic Disorders
- Anxiety Disorders and Panic Disorders
- Bipolar Disorder
- Defense Mechanisms
- Disruptive, Impulse-Control, and Conduct Disorders
- Dissociative Disorders
- Eating Disorders: Anorexia & Bulimia Nervosa
- Electroconvulsive Therapy
- Major Depression
- Personality Disorders
- Psychological Therapies
- Psychosocial Theories
- Schizophrenia
- Sexual Dysfunctions, Paraphilias, and Gender Dysphoria
- Somatoform Disorders
- Stress and Anxiety
- Substance Abuse Disorders
- 225 Nursing Bullets: Psychiatric Nursing Reviewer
This section contains the study guides and nursing notes for Nursing Pharmacology to help nursing students and healthcare professionals grasp the pharmacological principles and medication management. It provides detailed information on drug actions, uses, and nursing considerations, including patient education , covering a spectrum of medications from Acetaminophen to complex drugs like Adrenergic Agonists and Antineoplastics. This guide is instrumental in enhancing pharmacological knowledge and improving patient care .
- Acetaminophen Nursing Considerations & Patient Teaching [Drug Guide]
- Adrenergic Agonists (Sympathomimetics)
- Adrenergic Antagonists (Sympatholytics)
- Adrenocortical Agents
- Albuterol Nursing Considerations and Patient Teaching [Drug Guide]
- Anthelmintics
- Anti-Infective Drugs
- Antianginal Drugs
- Antiarrhythmic Drugs
- Antiarthritic Drugs
- Antibiotics (Aminoglycosides, Cephalosporins, Penicillins)
- Anticholinergics (Parasympatholytics)
- Antidepressants
- Antidiabetic Agents
- Antifungals
- Antihistamines
- Antihyperlipidemic Drugs
- Antihypertensive Drugs
- Antineoplastic Agents
- Antiparkinsonism Drugs (Dopaminergics, Anticholinergics)
- Antiprotozoal Drugs
- Antiseizure Drugs
- Antitussives
- Antiviral Drugs
- Anxiolytic and Hypnotic Drugs
- Aspirin Nursing Considerations and Patient Teaching [Drug Guide]
- Atorvastatin (Lipitor) Nursing Considerations and Patient Teaching [Drug Guide]
- Bronchodilators and Antiasthmatics
- Cardiotonic-Inotropic Drugs
- Cholinergic Agonists (Parasympathomimetics)
- Decongestants
- Drugs Affecting Coagulation (Anticoagulants, Antiplatelets, Thrombolytics)
- Enoxaparin (Lovenox) Nursing Considerations and Patient Teaching [Drug Guide]
- Expectorants and Mucolytics
- Female Reproductive System Drugs
- Furosemide Nursing Considerations and Patient Teaching [Drug Guide]
- Gabapentin Considerations and Patient Teaching [Drug Guide]
- General and Local Anesthetics
- Generic Drug Name Stems Cheat Sheet
- Glucose-Elevating Agents
- Heparin Nursing Considerations and Patient Teaching [Drug Guide]
- Histamine-2 Antagonists
- Hydromorphone (Dilaudid) Nursing Considerations & Patient Teaching [Drug Guide]
- Hypothalamic Agents
- Immunostimulants (Interferons, Interleukins)
- Immunosuppressants (Immunomodulators, Interleukin Receptor Antagonists)
- Inhaled Steroids
- Lisinopril Nursing Considerations and Patient Teaching [Drug Guide]
- Lung Surfactants
- Male Reproductive System Drugs
- Metoprolol Nursing Considerations and Patient Teaching [Drug Guide]
- Muscle Relaxants
- Narcotics, Narcotic Antagonists, and Antimigraine Agents
- Neuromuscular Junction Blocking Agents
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Related Agents
- Pantoprazole Nursing Considerations and Patient Teaching [Drug Guide]
- Parathyroid Agents: Bisphosphonates, Calcitonins
- Pharmacology Nursing Mnemonics & Tips
- Pituitary Drugs
- Proton Pump Inhibitors
- Psychotherapeutic Drugs
- Salicylates
- Sulfonylureas
- Thyroid Agents
This section contains nursing notes and study guides on nursing theory and notable nurse theorists aimed at helping students grasp core concepts and understand the backgrounds of these theorists . The guide offers brief overviews of key nursing theories , ranging from Betty Neuman’s Systems Model , which blends biological, psychological, and environmental elements, to Dorothea Orem ‘s Self-Care Deficit Theory, which focuses on the importance of patient self-care in health and wellness.
- Betty Neuman: Neuman Systems Model
- Dorothea Orem: Self-Care Deficit Theory
- Dorothy Johnson: Behavioral System Model
- Faye Abdellah: 21 Nursing Problems Theory
- Florence Nightingale: Environmental Theory
- Hildegard Peplau: Interpersonal Relations Theory
- Ida Jean Orlando: Deliberative Nursing Process Theory
- Imogene King: Theory of Goal Attainment
- Jean Watson: Theory of Human Caring
- Lydia Hall: Care, Cure, Core Nursing Theory
- Madeleine Leininger: Transcultural Nursing Theory
- Martha Rogers: Science of Unitary Human Beings
- Myra Estrin Levine: The Conservation Model of Nursing
- Nola Pender: Health Promotion Model
- Nursing Theories and Theorists: The Definitive Guide for Nurses
- Sister Callista Roy: Adaptation Model of Nursing
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18 thoughts on “Nursing Notes and Study Guides for Nurses”
I will be joining nursing training school in Ghana next year so I want to learn before entering, I will apply for general nursing
That’s awesome you’re starting nursing school in Ghana next year! Getting a head start is a great idea. Brush up on some basic anatomy and nursing concepts if you can. If you need any tips or resources, feel free to ask. Best of luck on your nursing journey!
Hi! I am a 2nd yr adult nursing student and I wanted to ask are these notes suitable for UK student nurses or are they more for American student nurses? I just want to make sure that I don’t end up studying the wrong thing? Thank you
Hi Po, Hey there,
Great question! Our notes and materials are primarily tailored for American nursing students, so they align more closely with U.S. standards and practices. However, many fundamental concepts in nursing are universal, so you’ll likely find a good amount of overlap and relevance to your studies in the UK.
It’s always a good idea to cross-reference with your UK-specific materials or curriculum to ensure you’re on track with the specifics required for your program. If you have any particular topics you’re curious about or need help navigating the differences, feel free to ask. Always happy to help out where I can!
Can I get notes on sociology and anthropology please I am a 1st year student in kenya
Hi I’m Mulki,thanks so much for this
Very nice and toomuch usefull content for the Nursing aspirants
Can I use Nurseslabs in the uk As it is NCLEX?
I am nyumu from Kenya and I am not yet joined the nursing school I want to read before and by this notes I am 💯%i will thankyou
I am kenneth from uganda. I have not yet joined nursing but i would like to go through these before joining
I need pathology
Very useful
Soooo helpful! Can you add study guide or nsg notes about Nursing research too? 🥺
Hi I am a Registered Nurse,I regularly use Nurseslabs website,this is not only enhance my skills but as well as great opportunity to aware from current developments in Nursing. Thanks
I am a 1st year college student who will take a nursing course and I am a bit worried and scared a lot cuz I am a slow learner and broke. Also, my class will start next week. I’m so thankful that I discovered this website before my academic year started, this will be my bestie website till the day that I am a PH-USRN. Thank you so much for making this website accessible.
Hello, thank you so much for this beautiful material. I have sent an email to your team, I will really appreciate your response to my email. Thank you in advanced.
Hi, I’m Joseph, a Psychiatric Nurse (A National Service Personnel – almost ending to be employed) in Ghana. Please i need a comprehensive notes on the above Psychiatric conditions. I will really appreciate if you could help me the notes. thanks in advance…
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Career Advice > Professional Development > Upskilling and Promotions > How to Write a Good Nursing Note: Example and Tips
How to Write a Good Nursing Note: Example and Tips
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A nursing note describes the reason for a patient’s care, interventions, their response to the interventions, and their overall progress. Documentation is an integral part of healthcare , so honing this skill is definitely worth your time. Keep reading to learn about why nursing notes are important, tips for drafting your own, and a nursing note example.
Why Write Nursing Notes?
Nursing narrative notes facilitate communication between the healthcare team by detailing a patient’s progress. Having proof of a patient’s care can be useful for a variety of reasons. Oncoming nurses can read them to learn more about their assignments, the nurse who wrote the documentation can refresh their memory, and other healthcare workers can see the results of their interventions.
These notes are also used for other activities indirectly related to patient care, such as health insurance companies using them to assess the cost of care, or as a written record in the event that legal action is taken against an individual nurse or facility.
Nursing Note vs. Charting: What’s the Difference?
Nursing notes are a form of charting, but not all charting equates to a nursing note. Nursing narrative notes include more details than routine charting because they provide a general overview of the situation on top of patient progress.
Sometimes, charting places more emphasis on day-to-day changes. An oncoming nurse who’s unfamiliar with the patient will likely still have plenty of questions after reading the specific bits of information and data described in typical charting, but would get a more thorough idea of the situation from a nursing note.
What to Include in Nursing Notes
- Patient’s name and demographic information
- Objective and subjective data
- Interventions
- Outcome and evaluation
- Treatment plan
- Chief complaint
- Relevant history
- Medications
What to Avoid in Nursing Notes
- Non-specific wording
- Premature charting
- Symptoms without an intervention
- Personal assumptions
How to Write a Good Nursing Note
With all this background on what to include in a good nursing note example, you must be wondering about how to realistically draft one. Below, we describe how to write a nursing narrative note.
1. Be Specific and Detail-Oriented
Notes are an essential part of team communication. Coworkers will rely on your note, so it’s important for you to be as clear as possible. On top of that, nursing notes can be used as legal documents in the event of a malpractice suit . If you’re called to testify, you may not remember many details. You’ll have to rely on your documentation to do much of the speaking on your behalf.
2. Name the Colleagues With Whom You Interacted
Identifying your coworkers will save other team members time and energy. Instead of trying to figure out who did what, they’ll know exactly whom to approach when they have any questions or concerns about decisions regarding the patient’s care.
3. Keep It Simple
Short sentences and simple words are easier to understand than long sentences with elaborate language. This is especially important when you consider all of the stressors that can arise in healthcare environments.
4. Prioritize Objective Data
Your coworkers will be the most concerned with the facts, so ensure you include them in your note. The patient’s subjective experience is important, but information such as vital signs, lung sounds, and the patient’s visible appearance are the main drivers of the care plan . Why? Because they show what the body is communicating to you and what the patient may not be able to articulate.
5. Address the Chief Complaint
It’s important to describe progress, or lack thereof, regarding the reason the patient needs medical assistance in the first place. It can’t hurt to include other health-related details, but make sure to prioritize their chief complaint and anything directly related to it.
6. Remember to Sign Your Name
This seems like a no-brainer, but it’s a detail people may forget when in a hurry. For the sake of clear communication, it’s important for your coworkers to know who wrote the note. On top of that, a nursing narrative note isn’t complete without a signature.
Nursing Narrative Note Sample
Reading a nursing note example will help you gain a better understanding of what’s expected of you. Check out our sample below for some guidance.
XX/XX/20XX X:XXpm
The patient is a 64 year old female whose chief complaint is an exacerbation of chronic migraines. Patient reports an 8/10 pain level that decreases to 7/10 on the current prescription of 600mg of ibuprofen once a day. Patient states she feels nauseous, which is a common symptom of her migraine exacerbations. She describes the quality of migraine as a “stabbing, throbbing feeling.” Patient states she struggles with bright lighting and loud sounds because they worsen her migraines. In these instances, she says her pain score rises to 9/10.
Patient is AAOx3. HR=95 bpm, RR=20 bpm, T=98.6, BP=130/90, PO2=98%. Bowel sounds present and bowel movements remain regular. No complaints of impaired vision nor memory. Patient states there are no life stressors adding to her current migraine exacerbation. Patient states her sleep schedule is normal.
Mayowa Okumba, APRN, ordered a basic metabolic panel (BMP) and an MRI scheduled for tomorrow. Patient is aware and consents to these procedures. Will continue to monitor vitals and for any other signs of discomfort.
Cherise McDonald, RN
Nursing Note Useful Tips
Here are some tips to keep in mind to help you write a useful nursing note example of your own.
1. Record Key Details Throughout the Day
You’re responsible for juggling a lot of information, and it’s perfectly normal for small details to slip your mind. Those seemingly little details could be important to the big picture. Jot down any details that stand out to you as soon as possible.
Even if your reason is just a hunch, it can’t hurt to have it written somewhere until your mind understands why it was important. Write on something you won’t lose such as your report sheet or a small notepad. Just make sure you properly dispose of them to protect the patient’s private health information.
2. Create a System That Works for You
To avoid missing key details, build a nursing note routine. Do you prefer to include vital signs first or the patient’s chief complaint? Do you include objective data followed by subjective descriptions, or will both be intertwined throughout the note? Is there a specific nursing notes template you prefer? Having a system makes it easier to ensure you don’t miss anything.
3. Imagine Reading Your Own Note With Fresh Eyes
If you feel like you don’t have a clear picture of the current situation and impending actions after reading your note, why would anyone else? When you’re finished documenting, reread your note to ensure others can readily understand the most valuable information from your shift.
What Did You Learn From Our Nursing Note Example?
We showed you what to do, now it’s your turn! Strengthen your documentation skills so you can feel confident in your next role. Get connected with personalized nursing job matches in your location and specialty today.
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Table of contents, what are nursing notes .
Nursing notes are written records detailing the care provided to a patient, including observations, treatment plans, and interventions. They are essential for continuity of care and are a legal document.
How to write nursing notes
Good nursing notes provide a detailed legal record of a patient’s status, treatment, responses, and outcomes.
All nursing notes must be:
- Factually correct
- Accurate and detailed
- Current with exact time information
- Professional
Tips for writing nursing notes:
- Be sure to document the correct patient, and under your own name and login.
- Document as soon as possible. Don’t wait until the end of the shift.
- Report and document missed or late entries immediately.
- Document the issue, what you did about it, and the patient’s response.
- Document only what you see, hear, touch, smell, and do—avoid opinions.
- Document often enough and with enough detail to tell the entire story.
- Document all communications—include names, titles, time, statements, and actions taken.
Free-form notes: nursing narrative notes
Writing nursing notes in a narrative format means telling the patient’s story chronologically. The note will provide the information in free, written-out sentences.
An advantage is that notes in this format provide context and a fuller picture of the client’s situation, but they can be time-consuming to read and write.
Nursing note template: SOAP nursing notes
“SOAP” is short for “Subjective, Objective, Assessment, and Plan”.
- Subjective: complaints and symptoms
- Objective: vital signs and other measurable data
- Assessment: clinical judgment
- Plan: treatments/intervention plans
Giving nursing notes this structure creates easier reading to scan quickly and reduces the possibility of errors and oversights by providing a standardized, focused documentation.
SOAPIE nursing note example
The SOAP-format is often expanded to “SOAPIE”: Subjective, Objective, Assessment, Plan, Intervention and Evaluation.
An example for this format would be:
- Subjective: Patient states: ‘I feel short of breath’
- Objective: Vitals signs showed: BP 110/75; HR 100; RR 22; SpO2 89%
- Assessment: Patient displays fatigue and is pale, states “tiredness”..
- Plan: This RN contacted the charge RN, rapid response nurse, and primary care physician.
- Intervention: Oxygen 2 L placed on the patient via nasal cannula.
- Evaluation: SpO 2 increased to 95%, respiratory rate slowed to 18. The patient was transferred from the med-surg unit to the ICU due to unstable condition per healthcare provider order. Report given to ICU nurse; family notified of transfer.
Nursing note template (SOAPIE)
- Subjective: What did the patient report?
- Objective: Vital signs/lab values
- Assessment: What were your findings?
- Plan: Who did you contact?
- Intervention: Action/intervention(s) the nurse performed
- Evaluation: What happened after the interventions?
Good nursing note example: dos and don’ts
Following are examples of nursing note excerpts that show the dos and don’ts of how to follow the requirements of a good nursing note:
Make sure the nursing note is factual
Don’t: Patient seems like they are in pain.
Do: Patient grimaced and moaned when their leg was touched.
Interpretations and assumptions are not facts.
Make sure the nursing note is accurate
Don’t: There was a large amount of drainage.
Do: There was 150 mL of serosanguineous drainage.
“Large amount” as a quantifier leaves the information open to the reader’s interpretation. Stick to the facts and give them in the most detailed way possible.
Make sure the nursing note is complete
Don’t: Patient was taught how to check their blood sugar.
Do: Patient was able to correctly return-demonstrate how to check their blood sugar.
Include how the teaching was done and the proof that it was successful.
Make sure the nursing note is current
Don’t: Patient had an elevated temperature after breakfast.
Do: Patient had a temperature of 39.1°C (102.4°F) at 0900.
This example shows again that it is important to be specific, precise, and to give all the available information.
Make sure the nursing note is organized
Don’t: Patient had altered mental status, stomach pain, and could not recall their name.
Do: Patient had altered mental status with inability to recall their name and complained of dull stomach pain at a level of 5 out of 10.
Group related information together.
Make sure the nursing note is professional
Don’t: Patient uncooperative and would not take meds.
Do: Patient refused 0900 meds.
It is inappropriate to label patients as difficult, uncooperative, or use a negative description – simply state the actions, what happened, quotes stated and everything that may have kept you from taking measures you were supposed to. Leave out any personal perspectives, reactions, or feelings.
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Nursing Notes Examples: A Guide to Effective Documentation
Nursing Notes Examples – Nursing notes are an integral part of patient care. They serve as a vital communication tool between healthcare professionals, ensuring that everyone involved in a patient’s treatment is well-informed. In this article, we will explore the significance of nursing notes, their key components, and the best practices for documenting patient information effectively.
Table of Contents
Why Are Nursing Notes Important?
Nursing notes are essential for several reasons:
- Communication : They facilitate communication among healthcare providers, helping the medical team understand the patient’s condition and progress.
- Legal Documentation : Nursing notes can serve as legal evidence in the event of medical disputes, providing a clear record of patient care.
- Continuity of Care : They ensure that multiple healthcare professionals involved in a patient’s treatment can pick up where the last left off.
- Quality Care : Effective documentation leads to better patient care, as it aids in the assessment and management of the patient’s condition.
Components and Structure of Nursing Notes
Nursing notes are structured documents that follow a standardized format. Here is a breakdown of the typical components that make up a nursing note:
- The header contains the patient’s demographic information, including their name, medical record number, date of birth, and contact information.
Date and Time
- This section records the date and time when the nursing note is written. It is crucial to maintain a chronological record of the patient’s care.
Subjective Data
- Subjective data includes information provided by the patient or their family, such as their description of symptoms, pain level, or concerns.
Objective Data
- Objective data is the nurse’s direct observations and measurements. This can include vital signs, physical assessments , laboratory results, and any other quantifiable data.
- The assessment section is where the nurse provides their professional judgment of the patient’s condition. This includes identifying potential issues or changes in the patient’s health.
- The plan outlines the nursing interventions that will be undertaken to address the patient’s needs and concerns. It includes medications, treatments, and any changes in the care plan.
- The evaluation is a critical section where the nurse reflects on the effectiveness of the interventions and the patient’s response to treatment.
- The nursing note is always signed and dated by the nurse, confirming their responsibility for its content.
Crafting Detailed Nursing Notes
Nursing notes examples.
Now, let’s explore some nursing notes examples to provide you with a clear understanding of how to create effective and comprehensive nursing notes. These examples are structured according to the SOAP (Subjective, Objective, Assessment, Plan) format, which is commonly used in healthcare documentation.
Nursing Notes Example: General Assessment
Subjective: The patient reports mild to moderate abdominal pain, localized in the lower right quadrant. He rates the pain as 6 out of 10.
Objective: Vital signs stable, with blood pressure 120/80, heart rate 80, and respiratory rate 16. The abdomen is tender to palpation in the right lower quadrant. No guarding or rebound tenderness.
Assessment: Likely acute appendicitis. Pain is a concern.
Plan: Notify the physician for evaluation. Administer IV fluids and NPO (nothing by mouth) status in preparation for possible surgery.
Nursing Notes Example: Postoperative Care
Subjective: The patient is groggy and reports pain at the surgical site. Pain is rated as 8 out of 10.
Objective: Vital signs stable, with blood pressure 130/90, heart rate 92, and respiratory rate 18. Dressing over surgical site intact. Minimal serous drainage noted.
Assessment: Immediate post-op period. Pain management is a priority.
Plan: Administer prescribed pain medication as needed. Monitor the surgical site for any signs of infection or complications.
The Importance of Clear and Concise Language
Using clear and concise language is crucial when documenting nursing notes. Avoid jargon and acronyms that may not be universally understood. The notes should be comprehensible to anyone reading them, including patients.
Electronic Health Records (EHRs) and Nursing Notes
Electronic Health Records (EHRs) have transformed the way nursing notes are recorded. They provide a secure and easily accessible platform for documenting patient information. Nurses can now input data directly into EHRs, improving accuracy and efficiency.
Legal Implications
Nurses should be aware of the legal implications of nursing notes. Inaccurate or incomplete documentation can have serious consequences, including legal action. Always document facts, avoid speculation, and never alter records.
Common Mistakes to Avoid
Some common mistakes in nursing documentation include illegible handwriting, skipping sections, or failing to sign entries. Nurses should take care to avoid these errors to maintain the integrity of the patient’s medical record.
Tips for Effective Documentation
To ensure effective documentation, nurses should:
- Document in real-time or shortly after an event.
- Use objective and descriptive language.
- Sign and date each entry.
- Avoid leaving blank spaces or drawing lines for future entries.
Nursing Notes and Interdisciplinary Communication
Nursing notes are not exclusive to nurses; they serve as a communication bridge with other healthcare professionals. It’s essential to share pertinent information with the entire healthcare team to ensure comprehensive patient care.
In Nursing Notes Examples conclusion, nursing notes play a vital role in patient care and healthcare communication. Clear, accurate, and timely documentation is essential to provide quality care, protect legal interests, and maintain a record of a patient’s journey to recovery.
Are nursing notes only for in-patient care?
No, nursing notes are essential for all patient care settings, including hospitals, clinics, long-term care facilities, and home healthcare.
How often should nursing notes be updated?
Nursing notes should be updated regularly, especially when there is a significant change in the patient’s condition or when interventions are performed.
Can patients access their nursing notes?
In many healthcare systems, patients have the right to access their medical records, including nursing notes. However, this may vary by location and facility.
Please note that this article is for informational purposes only and should not substitute professional medical advice.
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What Are Nurses’ Notes?
What’s the difference between nurses’ notes and charting, what are some examples of nurses’ notes, when should nurses chart their notes, what should be included in nurses’ notes, what should not be included in nurses’ notes, 11 tips for writing excellent nurses’ notes — from a nurse, how to write great nurses’ notes.
Sep 05, 2024
Nurses learn early and often that patient care is the No. 1 priority — but charting is a close second. Balancing charting and meeting your patient’s needs can be tough but is a necessity to accurately relay all updates to various providers. In fact, according to Science Direct , interdisciplinary communication is required for high-quality care, and improving communication will ultimately help improve patient outcomes.
Think about it this way: A nurse, doctor, or any other healthcare professional coming on shift is only as good as the charting they have on the patient. Nurses’ notes are an integral part of this chart, so they should be accurate, up to date, and concise. But how much detail is too much detail? And how can you balance patient interaction with writing accurate nurses notes? You’re going to do a lot of charting and notating in your nursing career. These tips will help you make these assessments thorough, helpful, and less stressful.
Since nurses are patient advocates and often have the most contact with their patients, their notes provide the most complete picture of the patient’s health to the other health professionals and specialists involved in their care. These notes are the formal documentation that nurses make when charting, based on the notations and scribbles nurses gather during a patient visit. They may also incorporate charting by exception , a shorthand way of noting the “exceptions” or abnormalities the patient is experiencing by initialing lists and charts.
Keeping thorough and accurate notes is extremely important for maintaining effective communication between nurses and the medical staff, but if a malpractice case is ever filed, these charts will be used by the legal team involved. Considering that nurses care for a number of patients at a time, the formal notes taken on a patient will help a nurse remember the events of the day, the care provided, and the specialists involved if their ever sued or called as a witness .
Nurses’ notes are part of charting. They are short-form notations on pre-established lists (charting by exception), often with a one-paragraph summary that gives a picture of the patient’s health during the visit or time period.
Here are some examples of good nurses’ notes to give you a little more context:
- “When I walked in the room, the patient was blue and having trouble breathing. I called a Code Blue and started CPR. Then Code team arrived.”
- “Lung sounds clear to auscultation bilaterally. Color pink. No signs of respiratory distress noted. VSS. Patient eating 90% of his meals and tolerating well. No abdominal distention or emesis this shift. Patient ambulating adequately. Voiding spontaneously. No BM this shift. Patient’s weight remained the same. Spouse visited patient today. Bed rails up x4. No hazards in room. Call light within reach.”
When nurses talk about charting, they are usually talking about the computer chart. Because many hospitals and clinics are going paperless, the physical (clipboard) chart may only have the patient’s history in it, while the computer chart has everything that happened during this stay.
Ideally, you make quick notations during your visit and add more depth immediately after you leave the patient’s room, when the information is fresh and top-of-mind. American Nurse Today says making brief notes while assessing the patient will help you chart faster and give more accurate (formal) nurses’ notes right after your visit. This helps you move efficiently between each patient you need to see. Visit, chart, repeat.
The three thoughts to keep in mind when you’re writing these notes are:
- Will this help all other staff members working with this patient?
- Did this summarize the patient’s current experience?
- Would this help remind me of the patient’s condition and care five years from now if I ever need to testify on this case?
Because your notes are so important, Tricia Chavez, RN, educator from Redlands Community Hospital in Redlands, California, suggests you include:
- Patient’s Name
- Nurse’s Name
- Reason for Visit
- Vital Signs
- Assessment of Patient
- Labs & Diagnostics Ordered
- Evaluation of How Medical Interventions Worked
- Instructions/Education
- Family Interactions
- Recommendations & Observations
- Anything Out of the Ordinary
Lippincott Nursing Center states you should only include the facts, rather than your personal opinion. However, your opinion can be verbalized to other healthcare professionals so they can get a better picture of the patient (e.g., Social Services notified; request for one more day of stay due to patient unable to care for self at home).
Here are some other notations that cross an ethical line when put in formal/permanent notes:
1. Personal Information Regarding the Patients’ Family Members & Friends*
While it’s OK to give very generalized information on them (e.g., they visited), nothing personal should be included (e.g., they were intoxicated, unkempt, uncaring, etc.).
2. Dialogues You’ve Had About Patients Between Providers*
Instead of conversation details, just note that you’ve informed certain physicians.
3. Anything From the ISMP List of Abbreviations *
These are often misinterpreted and lead to medication errors.
4. Your Opinion*
Instead, report on your recommendations and the systems you have put in place or staff you’ve notified (e.g., this RN recommends social worker evaluate patient’s ability to obtain supplies needed at home upon discharge).
5. Negativity About Staff That Could Be Portrayed as Defamatory*
There should be another system for reporting staff issues within your organization. But there are ways around saying what you want to say. For example:
- You want to say: “The doctor isn’t concerned about something that I’m concerned about.”
- But actually say: “MD notified. No further orders.”
- You want to say: “I’m concerned the patient’s grandmother is abusive to patient.”
- But actually say: “Please evaluate grandmother for care after discharge” in Social Services order. Then, speak freely when Social Services talks to you in person.
As an aside, you should never chart after your shift. If, for whatever reason, off-duty charting is needed and/or necessary, you should comply with your employer’s instructions or seek guidance from your supervisor on how to handle the situation.
As a nurse since 2001 and mentor at my hospital, here is the advice I give to new nurses:
Tip #1: Be concise.
Instead of a long-winded note, just add pertinent facts and keep it short.
Tip #2: State the facts.
Chart what you see, hear, and do.
Tip #3: Read other nurses’ notes.
Everyone will have their own voice. But you’ll see how veteran nurses balance their facts with their insight.
Tip #4: Find a mentor .
Look for an experienced nurse who you trust to give you constructive feedback on your notes.
Tip #5: Write shorthand.
Keep shorthand notes while talking. Keep eye contact while writing shorthand keywords for your post-visit write-up. Then chart it as soon as you can after. For example, if your patient is describing sharp stomach pains, you might write “9/10 pain/LLQ.”
Tip #6: Chart after each visit.
Take five minutes to chart and write thorough nurses’ notes right away; that way, it’s fresh in your mind.
Tip #7: Summarize.
In the hospital setting, write an end-of-the-day note in each patient’s’ chart, starting in the morning and go through the entire day. A good summary is helpful to everyone involved with the patient. In the clinic setting, there should be a summary in each patient’s’ chart with every visit.
Tip #8: Note responses.
Express how the patient responded to treatment. Chart whether they adhered to advice given by you and the doctor.
Tip #9: Describe observations.
Write down all pertinent observations with the patient. For example, “color pink, swelling to lower extremities, pain 4/10.”
Tip #10: Never speculate.
We always want to write how we feel the patient feels, but this isn’t usually accurate. Instead, chart what the patient is literally saying.
Tip #11: Use your resources.
Know that you have resources around you. Use the nurses who have been around for a long time; their experience is invaluable. There are usually charge nurses or nurse managers you can utilize. It’s always better to ask for help than to not chart enough information.
Image courtesy of iStock.com/ Hiraman
Last updated on Sep 05, 2024. Originally published on Oct 29, 2018.
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Jennifer Tomaselli, RN, MSN, RNC is a contributing writer for Berxi. She has a nursing degree and works in Labor and Delivery and NICU. Jennifer is a freelance writer and editor specializing in nursing, healthcare, and fitness. She enjoys living in southern California with her husband and teenage son.
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