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.

[TigerGalLE, BSN, RN]

We use flow sheet to chart as well. I'm a new nurse and I usually write a narrative note as well. Esp if there is a lot going on with the patient. I'll chart my assessment on the flow sheet and then add a narrative.. The vitals are on the flow sheet as well,. for example..

0800: AM assessment complete via flowsheet. Resp even and unlabored. No distress noted. O2 on a 3L via NC. Alert and Oriented to person and place. Confused about time, reoriented easily. Foley patent draining clear yellow urine. 1/2 NS infusing at 100ml/hr via 20g IV gelco in R forearm; site without redness or edema. Denies pain or needs. Instructed to call for assistance. Verbalized understanding.

1000: Pt c/o headache 5/10. Lortab 5 given PO for pain.

1100: Pt states pain relieved to 1/10.

1130: SQBS 160. 2 units Regular insulin given SQ for coverage.

1230: Pt OOB to chair for lunch with assistance from PT. No distress noted. Denies pain or needs.

1345: Pt back to bed with assistance. Instructed to call for assistance. Verbalized understanding.

1500: PM assessment complete. No change in assessment. Pt resting in bed without distress. Denies pain or needs. Instructed to call for assistance. Verbalized understanding. Visitors at bedside.

1545: Unable to flush 20g IV gelco in R arm. Removed with tip intact. Site has minimal swelling, nontender. New 20g IV gelco placed in L arm on 1st attempt. 1/2 NS infusing at 100ml/hr without difficulty. Tolerated well.

1630: SQBS 130. No coverage required.

1645: Pt to XRAY via stretcher. No distress noted.

1800: Pt returns to room via stretcher. No distress noted. No changes in assessment. Denies pain or needs. Instructed to call for assistance. Verbalized understanding.

[Mitch T]

Here are a couple of examples. And, if I witnesses a consent, I would have included that in the second one as well. I also developed a charting page with pull down menus at http://assessment.homestead.com

Example:

2/5/2007 P: The patient has not urinated in 6 hours since arriving at

1345 hospital. IVFs at 125 mL/hr. Patient unable to get up due to doctor's

order for bedrest. Patient NPO as ordered since hospitalization.

Patient reportedly received 4mg of Morphine IV in ED for pain.

I: Assisted patient with bedpan. Water turned on at faucet.

E: Patient still unable to void. I: Notified Dr. John Doe of patient's

inability to void for last 6 hours since arrival. Foley #20Fr

indwelling catheter placed to dependent drainage using sterile technique as

ordered. E: 620 mL return of clear yellow urine in bag. Will

continue to monitor urine output. Mitchell Taylor, RN

PIE charting example:

03/23/09 1500 P: Ineffective Breathing Pattern since admission R/T right pleural effusion stated in the chart. Pt. has diminished lung sounds in the base on the right side and has fine crackles heard throughout the right lobe. O2 sats on 2L/NC 89-90% I: Pleurocentesis ordered by Dr. _______. Placed on 3 L/Nasal cannula as ordered. Increased HOB to 30o. Repositioned patient in bed every 1 hour. Monitored O2 sats to keep them > 90%. Encouraged coughing and deep breathing and assisted with splinting when coughing to minimize pain. Ceftriaxone administered IV as ordered. Assisted with Pleurocentesis procedure with Dr._______ at 1110. Returned 820 mL of brown, thin, liquid sent to lab as ordered. A JP drain was placed by Dr. ______ and connected to bulb suction. E: JP bulb drain output 65 mL of seroganguanous fluid the next hour. Right lung sounds improved, still hear some fine crackles throughout the right lobe, but improved sounds heard in the base of the right lung. Left lung remains clear. Sats improved to 98% on 3L/NC, able to decrease back to 2 L/NC. Will continue to monitor resp. status and esp. right lobe lung sounds.

[ylim]

Hello,

I was just wondering what the good nursing progress note for the patient's condition listed below.

Good nursing progress note:

1. patient's condition:

65 years

CVA

IVT

IDC

X-ray

2. patient's condition:

45 years

Head injury

Nuro Obs

BSL 1/24

CT head

ADLs

anxious

[kayleighac]

At my job we mostly only do narritive notes. Here's an example of one of mine. We are charting on the patient for uti.

Received resident awake resting in bed. Alert, verbally responsive. Continue with po atb therapy for uti. No ase noted. Tolerating well. Afebrile. No hematuria noted, no c/o dysuria. Good peri care rendered. Fluids encouraged as tolerated. All needs met by staff. In no acute distress. Call light within reach, will continue to monitor.

[kayleighac]

My general nursing notes that don't refer to a specific problem look more like this.

Resident alert and oriented x 4. Verbally responsive. PERRLA. Skin warm and dry to touch. Respirations even and unlabored. No sob noted. No cough/congestion noted. SpO2 98% at this time. Abd soft and non distended. Bowel sounds normoactive x 4 quadrants. Bladder non distended. Pedal pulses present and strong. Vitals stable. No c/o pain or discomfort at this time. Able to make needs known. Safety maintained. Call light within reach. Will continue to monitor.

Now I always look at any tubing attached the pt when I make rounds. Add this to ur general notes such as any oxygen, iv's, foley catheters, etc. Add it to ur charting for ex: f/c drainijng clear yellow output, >30cc/hr. Or contine on O2 2LPM via nasal cannula. Or iv site patent, no s/sx infection or infiltration. Hope this helps!

[nurseineleven]

I am in Qtr two at Galen college in San Antonio. They dont help older people much. They just showed me the door yesterday for failure to do an adequate job of nursing notes in Clinicals (med-surg class). I told them that it takes longer than ten minutes in an 8 hour clinical to HAND WRITE all the things that I should have assessed during my "shift". I told them I have the book "Charting made incredibly easy". The problem I am having is that they dont give any examples of how to write things! I had the clients vitals among other things but I failed to write down the lung sounds! Geez she never told me to do a full assessment, and I am not a mind reader. ANY feedback is great even if it is not nice...trust me they were very condescending. I will need to retake the class now and eleven weeks is a short amount of time for this.

[nurseprnRN, BSN, RN]

"... didn't tell you to do a full assessment"? OK, here you are: always do a full assessment. That should cover you for the rest of your education and your career:d.

I review a huge number of medical records in my line of work. If I could wave a magic wand to change one fool thing in charting, it would be assessments. The idea is that your assessment tells the next guy-- who could be the next shift, the nursing student next week, the new physician hired who's covering this patient for the first time next weekend, the chart auditor next month, the legal nurse consultant five years from now-- what you saw, heard, and felt so clearly that that person can see what you saw, heard, and felt as if s/he were there. Stop and think. If you aren't a terrific creative writer, then you need a structure to focus on to make sure you don't miss anything. I do top-to-bottom, as in:

Subjective: "I feel alright. Can I go home soon?"

Objective:

Neuro: awake, alert, answers orientation questions accurately. Moves left side wnl, right arm purposeful with strength 3/5, right leg flaccid to painful stimulus, upgoing babinski. Pupils equal and react to light and accommodation appropriately. Denies pain, specifically incisional or headache.

Cv: legs warm to knees, feet cool, slightly mottled l>r, 2+ pitting edema, capillary refill

Pulm: chest clear in upper lobes bilat, diminished at bases, no rales or ronchi. Cough to request productive of small bolus of grey-green sputum, reminded to deep breathe every hour.

Gi: ng tube draining small amounts of yellow bile, air vent patent, air bolus heard left of xiphoid, + bowel sounds all quadrants, no stool, no nausea. Abdomen slightly tense, painful to palpation, sutures intact.

Gu: foley Dr copious amounts of light urine, sp grav 1.003 after furosemide IV; no scrotal edema, foley taped to abdomen.

Skin: slightly diaphoretic after acetaminophen suppos at 0600 for temp 38.2. Abdominal dressing changed for small amount serosang drainage; wound vac on left lower leg intact, skin slightly reddened over sacrum, damp, see braden scale flow sheet.

Psychosocial: tense, wringing sheet between hands, says, "Where is my wife? She said she would be here and bring my sister this morning."

Assessment: satisfactory recovery from bowel resection postop day 3; anxiety; risk for skin breakdown, risk for pulmonary stasis

Plan: out of bed x 2 today, cough/deep breathe q hour, plan ng clamp trial/removal, plan foley removal, skin care q4h.

At the end of the shift, discuss changes, how the day went, etc.

I hear wailing: I don't have time for all that!! OK, then when that case comes to court and I have to testify as to standard of nursing care... Well, what do you want me to say? Practice, practice, practice... It does get faster and more focused with time. Tell me what you see, tell me why you plan to do what you plan to do. Do not chart "Ivs and meds given as ordered," because it is assumed that you will be following the medical plan of care. Tell me what nursing care you saw necessary and performed, and how it worked.

[caliotter3]

Thank you GrnTea for a thorough and thoughtful example.

[Aeterna, BSN, RN]

We are supposed to chart by exception where I work, but I like to do a little narrative charting simply because I find it gives a much better picture of what went on that day and shows you actually looked at everything you were supposed to. Sometimes, though, I'll write less, particularly if the patient is palliative (as we are also a palliative unit). We use the DAR charting method on our floor. For me in particular, I give each section its own sub-heading.

For example, I will chart on how I found the patient and if their vitals were stable (I.e. "Patient received awake and alert in bed. VSS and afebrile. Oriented x3). I'll finish off the line, go to the next and document on another subject, such as the patient's respiratory status, IV lines, etc.

I pretty much note these for every patient:

- Any abnormal vitals

- Orientation/confusion/LOC

- Pain

- Respiratory status (I.e. lung sounds, shortness of breath, if they're on O2; our O2 sats and resp rates are on our flow sheets)

- GI (I.e. abdominal distension or discomfort; bowel sounds; if they have a colostomy, then I note that; if a patient has a normal looking abd and has been having good BMs, I may not chart this area)

And the "PRNs" of my charting, so to speak (as in, I do chart on them if it applies to the patient):

- Any IV lines (I.e. which IV fluids they're on and the rate; central lines and their dressings; saline locks; condition insertion/exit sites)

- Feeding tubes (I.e. if they're intact and flushing well; what type of feed and the rate; dressings if applicable; gastric residual volumes)

- Drains (I.e. what types; if and what they're draining; dressings, if applicable)

- GU (I.e. if they have a Foley; if they use a urinal or bedpan or if they are incontinent)

- Skin (I.e. any dressings, rashes, pressure ulcers or developing pressure ulcers, edema)

- Activity (I.e. if there are orders to ambulate the patient or get them up to a wheelchair, I document if the patient has been doing this and how, such as how many people need to assist, or if they are refusing; if the patient is normally up and about or is supposed to be on bed rest, I skip this)

- Behaviour (I.e. if the patient is having behavioural issues, such as aggression, calling out, etc.)

- Swallowing (if the patient shows any difficulty with it)

If the patient is getting anything "out of routine", such as blood products or chemotherapy, I document those very carefully, as well.

As you can tell, my nursing notes can be short or long depending on the patient. If they have a lot of tubes, then for sure my note will be long