Nursing notes

  1. 0
    As a student, I'm having difficult time writing nursing notes....It's crazy, I feel like holding both sides of my head and driving it straight to the wall!

    It's been about 8 days since we started clinicals...even the most simplest thing...I can't describe...So much in hand to study....Any ideas??



    KAL
  2. 12 Comments so far...

  3. 1
    Quote from mandykal
    As a student, I'm having difficult time writing nursing notes....It's crazy, I feel like holding both sides of my head and driving it straight to the wall!

    It's been about 8 days since we started clinicals...even the most simplest thing...I can't describe...So much in hand to study....Any ideas??



    KAL
    We've all been there sweetie! Our one instructor told us to just write down EVERYTHING you do. But that didn't fly with another instructor who told us it should be "short and sweet". If you talk to your instructors, i'm sure they will be happy to help you--that way there you can see the style that they prefer. Good Luck!!
    Namu likes this.
  4. 1
    Short and sweet is best. Use direct language.
    Old RLQ dressing removed, dried drainage noted. Area cleansed with ______, incision edges well approximated and staples intact without redness or active drainage. New ______ dressing applied and secured with _____tape.
    Jayden8139 likes this.
  5. 0
    What book can i buy to improve or better my nursing notes any sugestions will be greatly appreciated..Thanks!!
  6. 1
    see this recent thread on narrative charting:
    zenurse likes this.
  7. 0
    ok, i can understand the frustation that you were felling because now is my turn!:angryfire im a student nurse in a similar situation. but in my case i just happened to be a ESL student (English as a Second Language) .
    As a ESL student Is so hard to content my teacher because nurses have a very specific VOCABULARY that they use. and anthing diferent or less descriptive is just unaceptable.
    did you find a good book that help c your narrative notes?
    any tips that u can give me?
    any help will be HIGLY apreciated
    thanks
  8. 0
    I am in med-surg right now so taking notes is a must. What I do is I write down what I feel is important and that is basically something the instructor would repeat many times and i would also research it to get a better understanding. One intructor told to basically walk with books and notes attached to your hand.
  9. 0
    I'm not sure if your teacher approves of this, but I had many teachers who let me write a rough draft on scratch paper first before writing it in pen on the patient record. I am quite horrible at making some stupid mistaks on the flowsheet, and then making an even bigger mess when correcting it

    Now as a graduate nurse, I am fearing the nursing notes all over again! LOL, overcome one obstacle (school) for many new ones. But its worth it guys!
  10. 3
    Hi all, I am new here an just browsing. I'm the Satff development coordinator and ADNS ot a SKilled Nursing and LTC facility. I hope this helps someone. I know it helps my nurses.


    Skilled
    Admission Note Highlights: EXAMPLE

    1. Resident admitted to rm#___, time, from what facility, via _______ (? ambulance), # of attendants, transfer by #____ from stretcher to bed, with _______ (extensive/limited/ supervision) assist of #___.
    2. Resident requires daily skilled nursing level of care R/T Dx of : list primary Dx’s
    3. Mental status ie. A+Ox3
    4. Mood ie. Pleasant and cooperative
    5. Neuro status ie. PERLA
    6. Assessment of any relative organ systems
    7. VS and O2 sat: on room air or oxygen. Oxygen via _______at ____L/m
    8. Bladder and bowel continence, voided?
    9. Bowel sounds, condition of abdomen ie soft, Last BM
    10. Appetite: ie. Ate 50%, ability to feed self
    11. Pain, note level on scale of 0-10, meds given and effectiveness

    12. All skin and Wounds issues: size, drainage, surround skin, wound bed, location, type, treatment
    13. Weight bearing status
    14. # of assist(extensive/limited/ supervision) with bed mobility and transfers
    15. Lung sounds

    16. Participation with therapy: PT/OT/ST
    17. Does resident have a DPAOHC? Copy obtained? Document your referral to SS if needed.
    18. Code status
    19. 2-1/2 side rails as enablers for bed mobility
    20. Oriented to call light and room
    21. Orders to pharmacy
    22. Sign note


    Daily Skilled Note Highlights: EXAMPLE
    1. Resident requires daily skilled nursing level of care R/T Dx of : list primary Dx’s
    2. Mental status ie. A+Ox3
    3. Mood ie. Pleasant and cooperative
    4. New orders
    5. Assessment of any relative organ systems (see BLUE skilled charting guidelines page at front of IDT notes for each note)
    6. VS and O2 sat: on room air or oxygen. Oxygen via _______at ____L/m
    7. Appetite: ie. Ate 50%, ability to feed self
    8. Pain, note level on scale of 0-5, meds given and effectiveness
    9. All skin and Wounds issues: size, drainage, surround skin, wound bed, location, type, treatment
    10. # of assist(extensive/limited/ supervision) with bed mobility and transfers
    11. Any changes in status and your response, ie. Called MD etc
    12. Participation with therapy: PT/OT/ST
    13. Sign note

    3/25/10LF
    fairyluv, Zz SN, and Nurse Mayda like this.
  11. 0
    How are so many old threads being dragged up lately? This thread is from 2007 and last reply was 2008. All the posters have graduated nursing school by now.


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