Documentation

  1. Dear Nurses, I've been a nurse for 20 years and I still never found a professional way to write my note without using the word, "NOTED". For example: Patient "noted" to have a severe non-productive cough. I DON'T WANT TO USE THE WORD "NOTED". What other word can I use in place of "NOTED"? BTW, I picked this word up from more experienced nurses than I.
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    About nurse4sale

    Joined: Aug '06; Posts: 63; Likes: 44
    Certified Peds nurse; from US
    Specialty: 15 year(s) of experience in Med/Surg., Geriatrics, Pediatrics.

    11 Comments

  3. by   MPKH
    You can say observed if you saw something--"patient observed to have a severe non productive cough." You can say patient reported something to you--"patient reported to have a severe non productive cough." In the same vein, you can also say stated instead of reported.
  4. by   nurse4sale
    Thank you, MPKH. I looked in the Thesauruses for another word to use other than "noted" and it came up with words that didn't go well with my assessment. The other words you mentioned, "stated, reported" would be perfect, but my patient can't talk. He's a pediatric patient, non verbal and mentally handicapped. If you come up with anymore words to use, it would be very much appreciated. Thank You.
  5. by   MunoRN
    You can just omit the word "noted", if you state findings in your note you are by definition "noting" them, writing in your note that you are writing a note is redundant.
  6. by   nurse4sale
    Thank you, Muno, but the word Noted has a totally different definition from the word Note.
  7. by   Nurse Leigh
    Indicated? If pt nonverbally lets you know what he's feeling or experiencing?
  8. by   MunoRN
    Quote from nurse4sale
    Thank you, Muno, but the word Noted has a totally different definition from the word Note.
    It actually doesn't, it's the verb form of the word "note". If you write "pt has a severe cough" in your note, you "noted" that symptom, in other words you are recording that you recognized that the patient has a severe cough.
  9. by   Libby1987
    Exhibited?

    I use observed regularly.
  10. by   dah doh
    Observed (most frequently used personally)

    Pt stated "..."

    Pt complained of "..."

    Or just state the facts...heart rate 150, BP 75/40. Pt awake, alert, oriented x 4. Pt denies weakness, dizziness, sob, or pain. Dr XYZ paged; awaiting return call.
  11. by   SilleLu
    VS stable, Resp nonlabored, no accessory muscle use, chest rise equal bilateral, wet cough severe at times, nonproductive. Lung sounds coarse and diminished...etc..
  12. by   JustBeachyNurse
    Patient has a productive cough.
    Observed to have a productive cough

    +productive cough
    +dry cough
  13. by   emmy27
    The only time I really use "noted" is to highlight when my own observations don't mesh with the patient's report ("Patient complains of "severe red rash to entire body and constant vomiting," no vomiting or rash noted.") Observed works in this context as well.

    Otherwise I agree, appending "noted" to an assessment finding isn't really necessary. The act of charting a finding *is* the same as saying you noted it. You don't have to say "noted" any more than you have to say "seen" or "found" or any other verb.

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