HELP! How to write a nursing note on a lesion

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I'm having difficulty putting my thoughts into words. I have an assignment on writing a nursing note for a skin lesion. If anyone can help me use the right words for documentation I would really appreciate it. Also, if anyone knows any good examples or websites that have examples of how to chart/write nursing notes that would be great too! I really want to learn how to document correctly!

Here is what I know: location of the lesion is on the right antebrachial,the color of the lesion is brown, the size is >1cm (3 cms), it has a symetrical shape, there is discrete distribution, there is no exudate, and i believe it is called a patch (it is a flat birthmark).

If anyone can help me make that sound more like a nurses note, I'd really appreciate it.

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Specializes in OB/NICU.
I'm having difficulty putting my thoughts into words. I have an assignment on writing a nursing note for a skin lesion. If anyone can help me use the right words for documentation I would really appreciate it. Also, if anyone knows any good examples or websites that have examples of how to chart/write nursing notes that would be great too! I really want to learn how to document correctly!

Here is what I know: location of the lesion is on the right antebrachial,the color of the lesion is brown, the size is >1cm (3 cms), it has a symetrical shape, there is discrete distribution, there is no exudate, and i believe it is called a patch (it is a flat birthmark).

If anyone can help me make that sound more like a nurses note, I'd really appreciate it.

Well I'm no nurses note expert but I'd just say: pt has a flat brown symmetrical patch/lesion to R antebrachial area, 3 cms in length with discrete distribution and no exudate.

Hope that helps! You pretty much had it! Just put it into a sentence. :)

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Thank you, I appreciate it!

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