NURSES NOTES (AHHHHH!!!)

  1. I have been a nurse for a year. I have not mastered writing a nurses note yet. I started off writing too much. Now i think i'm not writing enough. I am in over my head. I always have to get approval from another nurse because i'm not sure of myself. Is there any book or reference that someone can recommend? Charting in general is my very weak area. Admission notes, discharge notes, you name it, it's killing me. Helllp!
  2. Visit Vernie08 profile page

    About Vernie08, ADN, RN

    Joined: May '09; Posts: 40; Likes: 37

    6 Comments

  3. by   amy0123
    Documentation books

    I have a book on nursing notes, The Complete Guide to Documentation ,LWW the above thread is also helpful.
  4. by   csiyaoe
    I don't think you can ever write enough on your nurses notes.
    I've always heard to write your notes as if you could go to court at any time, and you want them to know everything that happened exactly the way it did.


    I don't think you have to write a book, but you never know it could end up helping you in the end.

    I've seen so many nurses write in quotations word for word what the patient said, and what the doc. said. Also I think their are classes that can help you see it from a layers point of view which will really help.

    I'm not a nurse yet, but I work in a E.R. and just wanted to help out by telling my experiense with working with nurses. Hope this helps.
  5. by   black angel
    Hey there,

    Nursing documentation is in deed a headache. As per taught in school
    " what is NOT documentated is NOT considered done in the eye of laws."
    It's perfectly fine to qoute exactly what the Dr, Patient or relatives say however,
    all these depends on circumstances too.
    I usually quote when it is gona be a potential complain ot affects the patient's health care professionals
    or relatives safety. This is to protect not just your patients but your license as a nurse..
    Alot of time U nvr know when things will happen and u may be called to the court after a few years
    And your documentations will savw you alot of trouble.... i sahre one incident with you.

    I Had a patient who needs to be transferred to the other ward due to discipline over flow.
    When I was at the receiving ward, my collegue called me and told me that the lab staff wana speak to me.
    I was informed by the lab staff that patient is MRSA +ve for blood culture. I informed the the receiving nurse
    about the results and also told her to informed to informed the team drs about it as the team drs were in her ward
    making rounds then. I documentated what I done. 3 weeks later, I was on annual leave and when I came bk,
    I was told by my NM that the patient whom I transferred had been disharged without treatment and was readmitted one week later and passed away in ICU for sepsis. When they tracked back the notes...
    Cos it was considered a negligence event.... So My documentations had saved me to go through the interrogations by the onvestigating board.

    It's better to write more then not write at all... U need to be factual and summarise the key points so that it will not become a essay..

    hope this helps.
  6. by   josinda421
    I at times use a book called: Mosby's Surefire Documentation 2nd Edition. It teaches you how, what, and when nurses need to document. I work in LTC and a new nurse at that and at times not sure what to include in my documentaion cause I feel like I'm just all over the place. But this book has really helped me out alot. I even tells me what to assess on a pt based on the situation and what to document based on the situation. But problem is, since I've bought the book I've only gotten a few chances to look at it. But it has loads of info and worth the money. You can find it at Barnes and Nobles.
  7. by   ®Nurse
    About 20 years ago, a nursing instructor taught me that the way to document nursing care is like "Painting a picture with words".

    I think it is still true today.
  8. by   Spritenurse1210
    Charting made incredibly easy is definately a book I would recomend. Has helped me tremendously!

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