How to write a good nurses note?

This is very informative thanx.

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.

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.

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??