Help with documenting.

[RegenerativeNurse, ASN, LPN, RN]

I was hoping someone could give me some simple bullet points on the basic information to include in documentation (nurses note).

I know how to write I've just always felt my notes were inadequate and lacking what's needed.

I'd just like to hear others platform/outline for their notes.

[shipmanmisty]

Hello!

Here is my daily documentation (example of course) I work 0630-1500 on a med/surg floor

0700 Note:

Report received. DX: diagnosis. Medical status (acute care/obs/swing). Code status. Pt. resting quietly in bed (or whatever the pt is doing when you enter the room). A&Ox3. Responds to verbal commands. Speech clear. On room air. O2 sat x%. VSQ4. Denies pain at this time (or reports pain 8/10 - PRN given). On Telemetry. NSR HR 60s-70s. Up x 1 assist. On whatever diet (if diabetic I state that have accuchecks AC/HS). Voids spontaneously (or have F/C to BSD w/ clear yellow urine). States LBM x/x/x. IV access 10g left FA w/ NS @ 125cc/hr site WNL. Bilateral TEDs noted. Assisted pt. to BR and to EOB for breakfast ( or whatever interventions you complete at this time). Bed in low position, side rails up x 2, call light in reach. Will continue to monitor.

Then I usually document my assessment (this is done as a check list in our program)

0900 note:

Pt. sitting up in recliner. AM meds given w/o difficulty. Pt. reports pain x/10. No complaints or requests voiced. SMIP, call light in reach.

1100:

I usually documented ADLs, Wound care, any PRNs, BSGs and insulins or simply what the pt. is doing at this time.

1300:

I usallly put what the pt. is doing at this time for example many of the pts have visitors at this time.

EX:

Pt. resting quietly in bed w/ family at bedside. SMIP, call light in reach.

1500:

Report given to oncoming shift. Pt. (what ever the pt is doing). Transferring care @ this time. SMIP, call light in reach.

My advice would be keep on top of documentation. Document any interventions as needed. Along w/ your 2 hr note. Hope this helps.

:)

[RegenerativeNurse, ASN, LPN, RN]

Hello!

Here is my daily documentation (example of course) I work 0630-1500 on a med/surg floor

0700 Note:

Report received. DX: diagnosis. Medical status (acute care/obs/swing). Code status. Pt. resting quietly in bed (or whatever the pt is doing when you enter the room). A&Ox3. Responds to verbal commands. Speech clear. On room air. O2 sat x%. VSQ4. Denies pain at this time (or reports pain 8/10 - PRN given). On Telemetry. NSR HR 60s-70s. Up x 1 assist. On whatever diet (if diabetic I state that have accuchecks AC/HS). Voids spontaneously (or have F/C to BSD w/ clear yellow urine). States LBM x/x/x. IV access 10g left FA w/ NS @ 125cc/hr site WNL. Bilateral TEDs noted. Assisted pt. to BR and to EOB for breakfast ( or whatever interventions you complete at this time). Bed in low position, side rails up x 2, call light in reach. Will continue to monitor.

Then I usually document my assessment (this is done as a check list in our program)

0900 note:

Pt. sitting up in recliner. AM meds given w/o difficulty. Pt. reports pain x/10. No complaints or requests voiced. SMIP, call light in reach.

1100:

I usually documented ADLs, Wound care, any PRNs, BSGs and insulins or simply what the pt. is doing at this time.

1300:

I usallly put what the pt. is doing at this time for example many of the pts have visitors at this time.

EX:

Pt. resting quietly in bed w/ family at bedside. SMIP, call light in reach.

1500:

Report given to oncoming shift. Pt. (what ever the pt is doing). Transferring care @ this time. SMIP, call light in reach.

My advice would be keep on top of documentation. Document any interventions as needed. Along w/ your 2 hr note. Hope this helps.

:)

This helped bunches! It helps me realize the little things I do that I completely forget to document because I'm running around (well at clinicals). Also this pointed out some weak spots I didn't realize I had either. I REALLLLYYYY need to work on remembering my abbreviation because to be honest you lost me a few times there.

Thank you so much. I'm going to start working on my notes ASAP. I know how important they are.

[shipmanmisty]

You're welcome. Glad it helps you out. I've been a nurse for 2 years now and I still have a hard time wording what I need to say. Practice makes perfect. :)

[ASPIRING2BGREAT]

I have no advise...but @RegenerativeNurse, thanks for your knowledge!

[RegenerativeNurse, ASN, LPN, RN]

I have no advise...but @RegenerativeNurse thanks for your knowledge![/quote']

You're welcome :)