Tips For Writing Nurses Notes

  1. 0 Does anyone have any tips, outlines or web sites they have come across for writing good nurses notes?

    I would appreciate any feedback.

    Thank you.
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  3. Visit  Encephala profile page

    About Encephala

    Joined Apr '04; Posts: 15.

    6 Comments so far...

  4. Visit  OntCaRPN profile page
    1
    Try looking up DAR format, I think it's a fairly often used note method.
    Data:
    Action:
    Result:

    For example .... D: pt fell
    A: staff picked him up, brushed him off and reinforced teaching re using walker
    R: pt safely used walker rest of shift

    Now that's fairly simplistic, but you get the picture. I had trouble with it at first because I wanted to write a chronological novel about incidents But it works well for most things.

    Hopefully you'll get more help than this.
    JoAnnS likes this.
  5. Visit  Encephala profile page
    0
    Thank you so much for your reply . I'll do some research on that ASAP.
    Quote from OntCaRPN
    Try looking up DAR format, I think it's a fairly often used note method.
    Data:
    Action:
    Result:

    For example .... D: pt fell
    A: staff picked him up, brushed him off and reinforced teaching re using walker
    R: pt safely used walker rest of shift

    Now that's fairly simplistic, but you get the picture. I had trouble with it at first because I wanted to write a chronological novel about incidents But it works well for most things.

    Hopefully you'll get more help than this.
  6. Visit  suzy253 profile page
    0
    Another type of charting we've used was focus charting. Here's a link to info & example:

    http://www.findarticles.com/p/articl...05/ai_n8880050
  7. Visit  TheCommuter profile page
    1
    Lippincott publishes a book for nurses and students regarding correct charting methods. It is entitled Charting Made Incredibly Easy, and it can be found in any major bookstore in the medical/nursing section. I have a book called Surefire Documentation, which also has some good pointers on charting. The issue of charting is very important, because it can save you from being sued after bad patient outcome and will prove the care you provided.
    mzrenegade68 likes this.
  8. Visit  Hopeslayer profile page
    0
    I have always charted what my head to toe assessment was, plus what they did, and any new orders, plus any other info that is pertinent to that patient. Something like.

    PT alert and oriented x 3. 0 c/o pain or discomfort. skin w/d. LS clear. BS + x 4, abd soft and non-tender. +pp's. N.O. APAP 650mg po TID. PT inc of bladder x 3. 72h bowel/bladder screen started.


    Something like that.
  9. Visit  JoAnnS profile page
    0
    Quote from ontcarpn
    try looking up dar format, i think it's a fairly often used note method.
    data:
    action:
    result:

    for example .... d: pt fell
    a: staff picked him up, brushed him off and reinforced teaching re using walker
    r: pt safely used walker rest of shift

    now that's fairly simplistic, but you get the picture. i had trouble with it at first because i wanted to write a chronological novel about incidents but it works well for most things.

    hopefully you'll get more help than this.

    hello:
    thank you for the tip. where exactly can i find information on the dar format?

    thank you
    joann


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