Nurses Notes

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    Does anyone know if there is a book on documenting in nurses notes? I am not good at it at all. I don't want to say too much or too little. A web site would also be helpful.
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  3. 7 Comments so far...

  4. 0
    Would love to see something too!
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    The best way I've learned is to look at others note. You will see things you like and things you say "that shouldn't be in there." You can borrow others ideas of what to put in notes and make them your own.

    At my job we have "precut" nursing notes if we want to use them. Like: orientation, behavior, and problems for the shift.

    Hope that helps!
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    here is a link to one book. Another good one is called Chart Smart, the A to Z Guide to Documentation.Amazon.com: Nursing Notes the Easy Way: 100+ Common Nursing Documentation and Communication Templates (9780975999868): Karen Stuart Gelety: Books
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    Tyvm SuperV!!
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    GrnTea likes this.
  9. 1
    I just bought this on iBooks!! Lets get reading!
    GrnTea likes this.
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    there is actually a book "Charting Made Easy". you can find it at barnes and nobles, and it goes through quite a few different types of documentation. Experience, though, is the best way to learn, as is practice and making some templates on paper to remind you what to include with each note. Hope this helps! THE ISBN for this book is 1605471968 and its cheap on amazon!
    GrnTea likes this.


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