What do you write in your nurse PROGRESS NOTES?

[LVHI_RN]

I don't know if I'm charting too much or too little... and I want to manage my time wisely. So I'm wondering, what types of things do you put in your nurse progress notes???

[vintagemother, BSN, CNA, LVN, RN]

I think this depends on your setting. I feel your pain as I have to do narrative charting and each nurse has told me they chart differently and my boss is of no help.

I'm sure some experienced posters on AN will help you out on this one.

In my facility, which is acute psych, I try to mention the current care plan and any issues related to it. I try to mention vitals, PRNs, side effects.

Some nurses say no signs of acute distress noted.

My friend works in a SNF and she was taught to mention their dx, and side rails up, bed low, call light in reach,

HTH!

[HouTx, BSN, MSN, EdD]

It's not supposed to be a novel. Remember Nursing Process?? Your notes should reflect the Care Plan. Anyone reading your notes should be able to see that you are performing interventions as outlined in the plan - and evaluating the outcomes of those interventions.... taking necessary actions (like calling the physician) if the interventions are not working.

So - instead of "patient sleeping", your note could easily be an evaluation of the pain control goal -- "no discomfort noted". Easy peazy.

Also - make sure you adhere to your organization's P&P on documentation.