How to write a good nurses note?

[Elaine Mickens]

When charting on a patient in long term care facility, please give an example of a good nurses note.

[NurseNightOwl, BSN, RN]

Anne36 said:

Im still working on my charting, its not that great yet. One thing I notice with the medicare charting is that they ask for things that I may not witness because they are ADL's or acceptance of Food, etc. Sometimes I read back on what other Nurses have written so that I can see good examples of charting. My biggest problem is even having time for charting at end of shift. Cant clock out late and no charting off the clock. One hall has at least 9 medicare charts. Then there are the careplans, etc.

YES!!!

[leqwedz]

This is very informative thanx.

[littlelimabean01, LPN]

I was a strong LPN 2011. I left the profession after a death of a home health patient that I cared for nearly 4 years. 2016 I have decided to re-enter this profession. I took the break d/t stress and came back after losing a very high paying job that was less stressful than caring for individual patients. I am now in a LTC/skilled nursing facility OVER NIGHTS, is the key word. I am having an extreme difficulty in proper charting, IMO. Of course most are asleep (resting quietly eyes closed). I of course do several rounds almost in excess to make sure my residents are safe, and breathing comfortably. I feel a serious void in What Am I Supposed to Chart!? Help please.

[IVRUS, BSN, RN]

littlelimabean01 said:

I was a strong LPN 2011. I left the profession after a death of a home health patient that I cared for nearly 4 years. 2016 I have decided to re-enter this profession. I took the break d/t stress and came back after losing a very high paying job that was less stressful than caring for individual patients. I am now in a LTC/skilled nursing facility OVER NIGHTS, is the key word. I am having an extreme difficulty in proper charting, IMO. Of course most are asleep (resting quietly eyes closed). I of course do several rounds almost in excess to make sure my residents are safe, and breathing comfortably. I feel a serious void in What Am I Supposed to Chart!? Help please.

Well, I would start off by asking what does your facilitie's policy say? Does the facility you work for require q 4 hour charting?? q 2 hr? q 8 hr? Then, what documentation format are you to follow? Are you on a computerized system? If so, then much of your charting should be a series of checkmarks, and narrative Nursing Notes are usually only done when something unusual or out-of-the-ordinary occurs. But again, check facility specific policies.

[littlelimabean01, LPN]

We only chart, on occurrences, skilled nursing patients, medicare and those scheduled for weekly charting. We are still on a paper system and we do have the form that goes over each body system requiring a series of check marks, then we have to write a narrative on the reverse side. All this is required only once per shift. Where I am struggling is; What to say! Aaagh! I can not bring myself to virtually copy the morning note, seems sooo wrong. Since it is Over night I do not get the interaction with my patients/residents that the day nurse does. So my notes end up looking like this:"2100 Resident in bed resting watching t.v. N/C of pain when asked. Took p.o. meds s problems. Breathing is even and unlabored. C/B with in reach." Also everyone that is required charting also has VS taken q shift and is recorded on the front side where we put all the check marks. Is my note acceptable??