nurse notes

[kskewes]

curious as to when to use nursing note in charting. As a new nurse i get different answers from people on when and what to use in a nurse note. should i always make a note when charting and what should the note consist of. thanks ahead for any help

[Rose_Queen, BSN, MSN, RN]

The best source for that answer would be your facility's documentation policy and procedure.

[Here.I.Stand, BSN, RN]

I typically write a note for anything that can't be conveyed through flowsheets. I'm not a fan of double documentation...who has time for that? I don't!

[Ruby Vee, BSN]

curious as to when to use nursing note in charting. As a new nurse i get different answers from people on when and what to use in a nurse note. should i always make a note when charting and what should the note consist of. thanks ahead for any help

You should always follow the documentation policies and procedures for your facility. If you're unsure what that entails or where to find it, THAT should be the question you ask rather than asking different people when it is appropriate to use a nursing note.

When you write a nursing note (as with any professional communication), you will want to use complete sentences with correct capitalization and punctuation. These days, when everything is typed, there's no excuse for lazy writing. Poorly written notes that aren't clear to the reader may get you into trouble.