Nurses Notes(What do I write??)

[Forever Sunshine]

Ok I am starting to get down WHEN to write a nurses note. But when I have to write a nurses note... I feel like I don't know what the hell to write lol. What are important details to mention in a nurses note?

[Nurse_Tricia, LPN]

P.S, I had no idea about the continue to monitor.. THanks a bunch as I am sure I have used that in past notes!!!!

[Forever Sunshine, ASN, RN]

Neither did I.

I try to read through the other nurses notes in the chart to get some ideas on what to focus on with my note but I don't want to make it seem like I steal their words. I want to write in my own words.

My school did nurses notes but again not "real world" nurses notes. They focused on doing a head to toe assessment.

[Nurse_Tricia, LPN]

I used the continue to monitor tonight.. when i gave initial dose of ABT for UTI. before end of shift charted that no adverse reactions noted at this time for my f/up.. thanks.. great little lesson!!!! :yeah:

[caliotter3]

Don't worry about stealing other nurses' words. We are not writing never before published novels. Sometimes there is one best way to say something and another nurse said it first. OK to use the same phrase if it applies.

[cakegirl]

LOL! That's very good!

[Twentyfiveyears]

Re: continue to monitor. I remember one of my instructors saying, in response to writing, "continue to monitor," at the end of a note, "well, I should hope so." Obviously, that instructore felt that that was unnecessary to say. Also, I agree that a nurses' note should not contain things like VS and other things that are already documented in your assessment/s, unless there was an issue. I tend to document things that are helpful to the docs and the oncoming nurse/s, and changes that are pertinent.