Like any other health professional, being a nurse can undoubtedly be hectic. However, this isn’t a surprise since, after all, you’re among the front liners in the event of a medical emergency. As a nurse, your primary task will be that of looking after your patients and charting. But the challenge comes where you have a hard time balancing attending to your patient’s needs and charting to ensure every detail you’re passing across to other health practitioners is accurate. In such situations, nursing notes become vital as they ensure smooth interdisciplinary communication: Thus, this helps boost communication and better patient outcome.
Therefore, it’s clear that nursing notes play an integral role in charting. But other than making sure that the nursing notes are concise, accurate, and up-to-date, there’s a lot more you need to know about nursing notes. If you’re searching for insights on nursing notes, look no further.
What Is a Nursing Note?
Nurses are the ones who spend the majority of the time with patients; hence their notes are essential in giving a clear to other medical professionals who are involved in taking care of the patient on their health. The nursing notes serve as formal documentation used by nurses as they chart during the patient visits. The charting by nurses is based on scribbles and notations. In addition, it can be done through exception, which is a shorthand technique of stating any abnormalities or exceptions experienced by the patient through charts and initialing lists.
Writing accurate and comprehensive nursing notes is essential to ensure there’s effective communication between nurses and other healthcare staff. Therefore, if there’s ever a malpractice case filed, it’s these charts that the legal team will use during the case. And because the nurse will be attending several patients during the day, writing down the nursing notes will help them remember clearly the care offered, the medical professionals involved, and the day’s events if ever needed to testify as a witness of getting sued.
Essential Elements of a Nursing Note
When writing nursing notes, there’s a lot more you should include other than the pages and titles stating “Nursing Notes” or “Progress Notes.” But before writing the nursing notes, there are three things you need to consider including;
- Will these notes be of use to other staff members who’ll be handling the patient?
- Do the notes review the patient’s present experience?
- Will the nursing notes help you remember the patient’s condition and care even after five years if you were required to testify in court on the case?
For a start, the nursing notes need to be viewed as a legal document, meaning they do have some degree of importance. Here are some of the details that must be included in the nursing note;
- The date and time
- The patient’s name
- The patient’s reason for coming to the hospital
- The name of the nurse
- The patient’s appearance
- The patient’s vital signs
- The patient’s initial assessment
- If any labs or diagnostics have been requested
- Whether any assessment of medical intervention has been carried out
- Any observations and recommendations
- If any specific importance has been given
- Whether the patient has had any interaction with their family
- If anything strange has been noticed
Nursing Notes Formats and Examples
The Importance of Nursing Notes
When writing nursing notes, there are several basic information and basic patient details that should be included, and these are;
- The patient’s medical history
- The patient’s current medical condition
- The patient’s appearance
In addition to this, you should also add other important details about a particular individual in the nursing notes, such as your observations. Consequently, you should give your sentiments based on the observations made. For example, most nurses write nursing progress notes once they’re done performing nursing assessments and tests.
The primary role of nursing notes is to offer relevant details on the patient’s overall medical status. With these notes, you get to keep a record of your patient’s observations. In addition, you’re expected to include both normal and abnormal patient activities and behaviors that you observed.
Using the details in the nursing notes, you’ll be able to monitor whether your patient shows any change in their condition and behavior over a particular duration. With these insights, you’ll be able to know what’s bringing about such changes. Likewise, a blank note can also be effective to act as a reminder to you, a fellow nurse or another healthcare professional of the patient’s overall condition. This ensures there isn’t any confusion on the patient’s condition while in hospital.
What Should Not Be Included
When writing the nursing notes, you must only include factual information and not your personal sentiments. With that said, you can still verbalize your opinion to other medical professionals to help them better understand the patient.
Knowing that, here are some of the crucial notations that you shouldn’t include in nursing notes as they go over the laid down ethical lines. These include;
- Personal details about the patient’s friends and family members include descriptions such as uncaring, drunk, or unkempt.
- Conversations you’ve had between patients between providers but rather than focus on dialogues with specific physicians.
- Using words from the ISMP list of abbreviations as this in many cases gets misconstrued, resulting in medication errors.
- Any negative information on other staff as this could be seen to be slanderous. You should instead opt for another ideal reporting system that’s been affected by the organization.
- You sharing your opinion rather than giving your recommendations and the systems you’ve made or other staff members you’ve informed.
How to Write
A nurse is always the one expected to write nursing notes and the templates followed when writing these medical or health records include;
- Correct nursing documentation and assessment
- If there are any observed changes in the patient’s condition
- The treatment or care which the patient has received
- Any other useful information to help the clinical team
Tips for Writing Nursing Notes
Before you can even start writing nursing notes, it’s best first to read over these practical tips that were noted from the best samples of nursing notes. Some of these tips include;
- Only state the facts, and this means adding only what you do, hear, and see.
- Be consistent throughout the notes and only record the patient’s information with each entry containing their full name and the date and time.
- Don’t be in a rush when writing the notes to ensure the notes are clear and neat.
- Ensure you write down the details on time, typically within 24 hours after supervising the patient. This means the next nurse will have a better idea of the patient’s condition when it’s time for their shift.
- Be short and concise by only stating the relevant facts.
- Seek help from an experienced mentor to learn how to share constructive feedback when writing your nursing notes.
- Clearly describe your observations you see being exhibited by the patient, for example, pain 5/10.
- Make sure to chart after every visit, and this should take you around five minutes. This is essential to ensure your mind remains fresh at all times.
- Always document every conversation you’ve had with the patient’s family members, doctors, and other medical staff while stating the patient’s overall condition.
- Make the notes as simple as possible by only mentioning relevant patient details. This is essential as the nursing notes should be read through quickly to include lengthy details.
- It’s best not to use abbreviations as they might have a different meaning to a different person, leading to miscommunication.
- Explain the patient’s response to the medication.
The nursing notes play a crucial role in ensuring optimal care is delivered to the patient. If you wanted to know how to write this formal document, this comprehensive article has explained every essential detail about nursing notes. With these insights, you now know how to go about writing these notes.