Examples Of Good Nursing Notes

[angel5113]

If you write good progress notes or come across any, would you mind posting them.

Hi everyone,

I'm new to this forum. I'm a new nurse, but I'm also in school (working to complete an MSN).

I found your site as a result of an exhaustive search on the internet for examples of good charting. I was taught the soap method in school. And there are plenty of examples of good soap notes on the web - problem is...Most of the examples are medical soap notes and are not applicable to nursing. There are also quite a few suggestions on "How to" write good progress notes (eg using dar, soap, soapie, soapier, pie, etc.). And

There are plenty of examples of bad nursing notes. But I spent 8 hours

Yesterday searching for actual "Examples" of good notes, with very little success.

I've purchased the books recommended in this forum for charting which should arrive in a few days. (charting made incredibly easy & sure fire doc...)

My unit charts by exception but the managers want the staff to start adding progress notes to the chart...Which they (staff) are reluctant to do (...Repetitive work argument - we're already charting on flowsheets). I was taught "Not documented, not done", so I see the value in narrative charting.

I'm reluctant to ask my manager or fellow nurses for fear I'll be targeted for the "Oh, she's not doing what her preceptor tells her to do...She's not doing it the way we do it...She thinks she's better than us... She's not going to make it list." I really don't want to rock the boat and start asking for stuff the other nurses are opposed to. But I still want to protect myself...And learn how to write good notes.

My thinking is...Medical students are given plenty of examples of good medical soap notes, why can't new nurses get the same help? As critical as charting is to legally protecting us and hospitals, why aren't new nurses given more examples of good nursing notes? There should be an abundance of good nursing notes out there...On the web, in med/surg books, clinical skills books etc.

Please help. I'm looking for examples of good charting (eg discharge notes, admission notes, progress notes etc.). If you write good progress notes or come across any, would you mind posting them.

[suzanne4, RN]

Are you using a basic flow sheet for most of your charting? If so, and you are supposed to be charting by exception, then you can get by with just a shift summary, and possibly one or two sentences at the beginning of your shift.

Narrative notes are being shied away from, who wants to read all of that? The only thing that needs to be in the narrative notes the rest of the time is something out of the routine for that patient. Such as a procedure being done to them, etc. The rest should be able to be documented on the flow sheet.

Hope that this helps.

(p.s. I learned with the old system also, once you get used to this new way, you won't want to go back to the old. ?

[begalli]

This was frustrating for me as well in nursing school. They never really teach charting by example, but sure did emphasize it!

[angel5113]

Suzanne,

Thanks for the reply. Yes, we are using flow sheets, and yes we're charting by exception, so it sounds like a shift summary would work.

[live4today, RN]

Welcome aboard allnurses angel! ?

Having graduated back in the late 1980's, where I went to college the nurses were taught how to chart. At that date and time, narrative charting was in use. I personally liked narrative charting at the time because then I had time to do narrative charting and give good care to each of my four or five patients. Today, nurses do not have time to do narrative charting on an inpatient unit, so charting by exception is also good.

I have a problem with the checklist charting method because I've come across many of those flowsheets where the nurses check off whatever was noted the shift before. I know because when I go into to do my assessment of the patients, I find things that were obviously missed in prior shifts (same old vital signs, different IVFs, stating dressings were clean, dry, and intact which I noted to be dirty, soiled with blood, hanging loosely from the wound, etc....JP drains that had been pulled were still being checked as being intact....many more....you get my drift). Checklist charting sometimes leads the nurses to rush through the shift charting for "lack of time to do it right".

I think it would be nice to have a system at every patients bedside where the nurse can do oral documentation as she/he assesses or does things for the patient that need to be charted. A button to push where the nurse can record as she goes along, with the tape recording mechanisms built in to each unit's audio system somehow. Like dictation. This also allows for patient/family/visitor interaction to be recorded that would cut down on "the patient/family/visitor always being right" theory...........calling the nurse "a liar". The protection goes both ways....not just one-sided.

[angel5113]

Hi Cheerfuldoer,

Thanks for the kind welcome. I agree with you regarding the checklist charting...I've seen that happen myself. I would like to get into the habit of doing it the right way. If you come across any good nursing notes would you mind posting them. I've seen plenty examples of bad notes posted on different websites and in articles...but I'm hoping to find examples of good notes.

Thanks a bunch,

Angel

[live4today, RN]

I'm currently not privy to any nursing notes since I'm between jobs right now. The nursing notes that I'm most familiar with are narrative or SOAP...and the awful checklist examples.

Many hospitals have gone to computer documentation, and some I like...some I think are not "nurse friendly".

If I do come across any down the road, I'll keep a blank copy of one to show here. ?

[Serenyd]

I've purchased the books recommended in this forum for charting which should arrive in a few days. (Charting made incredibly easy & Sure Fire doc...)

Have you ordered chartsmart? it has many examples. I am a GN and found it to be helpful - I have Surefire documentation and found it to be too short and to not have enough information in it for a new nurse.

Seren

[angel5113]

No I haven't. But I'll return Sure fire and order Chartsmart. Thanks for the headsup.

Angel

[seza]

I was woundering if anyone knew about Systems Narrative progress notes im from australia doing diploma of nuring and i8 need help??

[truerae]

angel5113 said:

No I haven't. But I'll return surefire and order chartsmart. Thanks for the heads up.

Hi! I got these charting examples when I went searching for nursing learning games. This site also had matching games & flash cards, videos, pharmacology tutoring, etc. Great site - I marked it as a favorite. 

https://templatearchive.com/nursing-notes/

2000- removed indwelling catheter without complaints of discomfort, draining 225ml clear yellow urine, instructed to notify nurse of next void p.Katz lpn (from truerae: I've been taught to chart "Catheter tip intact" to make sure that it all came out - on all catheters including ivs et you could also simply state "Tolerated well".)

A note to the student related to this charting- it is necessary to assess and make note of the first void after discontinuing the catheter:

1. It occurs within 4-6 hours after removal

2. There are no difficulties noted by the client or nurse.

3. Urine is "Normal"--example: watch for bleeding or other abnormal characteristics

• It is 10 pm and your facility uses military time.
• You have a client with an indwelling urinary catheter (14fr)
• The urine output has been 90 ml of cloudy yellow urine during the 3-11 shift
• Client's abdomen is rounded at the suprapubic area
• Client complains of an urge to void
• PRN orders per doctor: irrigate indwelling catheter with 50ml .09% sodium chloride PRN
• After irrigating the catheter, it returns 275 ml light cloudy yellow fluid.
• Pressure is relieved and suprapubic area is flat.

2200- states "I feel like I need to urinate", suprapubic area is round and semifirm, indwelling catheter with 90 ml cloudy yellow urine this shift, irrigated with 50 ml normal saline, returned 275 ml cloudy light yellow fluid, suprapubic area is flat, denies pressure or urge to void. P.Katz lpn

• it is 10 am and your facility uses military time.
• you follow the orders on the chart below
• you use a 14fr indwelling catheter
• the urine output is 375 ml of clear yellow urine
• there are no complaints or difficulties during the procedure..

1000 - inserted 14fr indwelling catheter, draining 375 ml clear yellow urine, 5 ml sterile water inserted in balloon, no difficulties or complaints.

0800 t-98.2, p-78, r-16, bp-108/72 a &o x3, pupils equal and reactive, moves all extremities with equal strength, respirations even & unlabored, lungs clear, abdomen is soft and nontender, bowel sounds x4, last bowel movement 4/11, void clear yellow urine without difficulty, cap refill

0800-alert and oriented x 3,anxious bp 108/60 pulse 110, respirations 20, temp 100.6, intact skin, warm and dry, pupils are equal and reactive, moves all extremities with equal strength, apical pulse 110 and regular, lungs clear anterior and posterior, respirations even and unlabored, abdomen is semifirm and tender, states- pain rated 10/10, bowel sounds present in 4 quadrants, voids clear yellow urine, moderate amount purulent lady partsl drainage, pedal pulses are positive, capillary refill

0800-drowsy and oriented x1,anxious bp 150/88 pulse 126, respirations 32, temp 102.2, intact skin, cool and clammy, pupils are equal and reactive, moves all extremities with weakened strength, apical pulse weak and regular, wheezes bilaterally anterior and posterior, bilateral retractions, productive cough with small amount yellow thick sputum, abdomen is semifirm and nontender, bowel sounds hypoactive in 4 quadrants, voids small amount dark amber urine without discomfort, pedal pulses are positive, capillary refill

1730-bp 110/60 p-102 r-20 t-38c, skin hot, dry, and flush, drowsy, oriented x3, pupils equal and reactive, apical pulse strong and regular, capillary refill

[rn undisclosed name]

The above is a good example, however, I have been taught to not chart when they are oriented x1. What exactly are they oriented to. Most people would assume they are only oriented to their name which is probably what the nurse was intending to convey. However if the person is not oriented x3 I specify what they are oriented to. For example, I would state alert/oriented x 2. Pt is oriented to person and place. Disoriented to time --> pt states it is January 1, 1957. Patient reoriented to time.

We do narrative charting and I don't really care for it. Sometimes I feel as though I am charting certain items on the same patients. I do state that pt is resting comfortably in bed. Side rails up x2. Call light in reach. Will continue to monitor.

Many times in narrative charting things are being charted in duplicate. Narrative charting is good for lung sounds where you can go into more detail such as crackles at bases, wheeze heard in certain lobe. I do use narrative charting to document the time I call a doc, what I am calling for and that I am awaiting a return call. If the doc does not call back I write paged x2. Awaiting return call. I once saw a nurse who wrote doctor not returning pages. Boy was that doc mad (and this was a doc who is so easy going and never gets upset). When a doc is not calling back there could be something wrong with their pager system that they're not aware of. There are other means to get a hold of a doc. They can always be called at home or on their cell phone.

If I have a patient for an emergent dialysis I chart what has been done and all communications. If this patient goes bad cause they're not getting their STAT HD done I am just CYA.

I'm always on the lookout for good charting myself.