How to write a good nurses note?

[Elaine Mickens, ASN, RN]

When charting on a patient in long term care facility, please give an example of a good nurses note.

[cwgrlup85, ASN, RN]

Well it would depend on what the resident it being charted on. For example a resident is on an abt for a uti, you would want to focus on: are they having any reaction to abt, are they continuing to have symptoms of uti, that you're encouraging fluids and if the resident is accepting. Ex: "Mary continues on abt therapy for uti with no adverse effects noted. Burning upon urination has subsided. Fluids are being encouraged intake 1500cc, output x6. T 98.4, p60, r 18, bp 120/60." I always tell my nurses to document as if you're painting a picture. Describe the situation or resident as if a stranger were reading the chart and you want them to know what you've observed.

[Anne36, LPN]

I'm still working on my charting, its not that great yet. One thing I notice with the medicare charting is that they ask for things that I may not witness because they are ADL's or acceptance of Food, etc. Sometimes I read back on what other Nurses have written so that I can see good examples of charting. My biggest problem is even having time for charting at end of shift. Can't clock out late and no charting off the clock. One hall has at least 9 medicare charts. Then there are the care plans, etc.

[chrisrn24]

Anne36 said:

Im still working on my charting, its not that great yet. One thing I notice with the medicare charting is that they ask for things that I may not witness because they are ADL's or acceptance of Food, etc. Sometimes I read back on what other Nurses have written so that I can see good examples of charting. My biggest problem is even having time for charting at end of shift. Cant clock out late and no charting off the clock. One hall has at least 9 medicare charts. Then there are the careplans, etc.

Wow really you can't stay late? Sometimes I have Medicare charting on 13 or so people and most of the time, I can only do a couple notes during my shift. I'm usually there for a hour or so charting afterwards.

[VANurse2010]

I see a lot of posts on this subsection talking about care plans. In my opinion, care planning is the responsibility of the unit manager or other admin. It's ridiculous to expect the pill pushing floor nurse to do care plans on top of pill pushing, treatments, and charting. I guess it depends on the staffing model, but if you have no admissions/treatment nurse, med tech, etc., it's not a reasonable expectation given the typical patient load.

[zieglarf, LVN]

Like it was stated earlier - what is the reason they are being charted on? Was there an incident? Anitbiotics? Monthly charting?

Our Medicare charting is on a checklist. So I check the appropriate boxes and flip it over to write nurses notes. If there was nothing unusual then I follow our 'guidelines' for MDS charting. The guidelines have what our MDS nurse says must be charted on. I memorized it as basically this...

VS - mental status - senses - eating - body/bed - bowels - skin

An example of my MDS charting might be...

"97.9 - 83 - 146/83 - 20 - 96% SAT on RA, resp. even and unlabored s SOB, A/O with confusion s c/o distress, medicated for pain prior to PT/OT c + effect, friendly with staff and compliant with care, hearing and vision adequate c glasses, feeds self in Dr with moderate appetite - consumes >75% of most meals, takes meds whole s difficulty, assist x 1 c transfers and ADLs, able to t/r self in bed c 1/2 SR ^ x 2 c assit x 2 to pull up in bed, cont. of B/B c occ. incont. episodes c care provided q2° and PRN, skin W/D s brkdown"

"97.9 - 83 - 146/83 - 20 total care for all needs D/T generalized weakness and cognitive issues, alert with eyes open, unable to voice needs, facial grimacing and moaning noted - medicated for pain c + results, ABT prophylactic s adverse reations r/t recent oral surgery, hearing and vision adequate, P/T patent and infusing @ 50ml/hr x 22 hr per day day c 150ml flush per shift, assist x 1 for ADLs and t/r, assist x 2 c transfers via hoyer lift, F/C patent and draining to gravity c clear, yellow urine, incont. of bowel c care provided q2° and PRN, skin w/d s brkdwn"

Other than MDS charting - I would focus on the reason they are being charted on. When I have a lot of charting then I keep it brief. When I have less charting then I elaborate a little more.

[ritaann]

Does s mean without "skin w/d s breakdown" ?

[CapeCodMermaid, RN]

Did you check their skin front and back head to toe? If not, I wouldn't chart they had no breakdown.

[mlbluvr]

One place I worked had so many 'intact' skin nurses notes on patients that actually had treatment orders, that after stand up the entire IDT went out to do skin checks, every week, on every patient.Talk about out of control, eh?

[ktwlpn, LPN]

It's good practice to get a note entered early in the shift, especially on your Med A or unstable folks. If you have EMR you can do it as you are passing them their meds. You can always go back and chart a more through assessment later on. Our EMR has templates and they are a great tool especially for inexperienced staff.

[lumbarpain, ADN, RN]

Working on a disorganized unit can really be upsetting......I am used to routinely doing things...on a time frame....however we know this is impossible at times when things go nuts......right now I am focusing on the problem that the Nurse Manager informs me about on a patient....it seems that this facility is very bad on good reporting..many things are omitted and why I have no clue when I give report..I expect to hear what I said was important BACK the next day so I know what happened......it isn't happening........I keep my own report book on my patients an follow up on what is done and not done......If a patient has a GT tube....I chart specifically on that....if hes on ABT.....VS and anything pertinent with that......until I start full time here...I will be able to track things better...only thing is we need another good full time nurse on the same unit and then the unit will flow better. Its very tough coming onto a unit that is highly disorganized and everyone is doing what ever......but...we shall see. if not...then we go elsewhere.

[systoly]

ktwlpn said:

It's good practice to get a note entered early in the shift, especially on your Med A or unstable folks. If you have EMR you can do it as you are passing them their meds. You can always go back and chart a more thorough assessment later on. Our EMR has templates and they are a great tool especially for inexperienced staff.

I'm a firm believer in early entrees even if it's just a one or two liner. Something about what they're doing, such as reading, watching TV, or listening to music.

I like to make these quick entrees right after my round, so if things go crazy I have at least documented that the pt. was seen, comfortable and involved in an activity. If the pt is not comfortable you gotta do something about it, of course, and chart that.