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I know nursing notes have been mentioned before, but....

Nurses   (1,773 Views 8 Comments)
by Garethaus Garethaus (Member)

3,515 Profile Views; 55 Posts

...I am seeking a definition of old school documentation of nursing notes. After searching the threads I cannot see exactly what I am looking for. I know there are many formats for documentation but the one I would like defined by somebody who knows, is constructed as the one that generally begins with:

Mentation: ie - Pt alert and orientated

Observations: ie - Obs within normal limits (or not, etc)

Input / Output.................................................gaps...............................................

......finishing with possible plans for discharge of patient / Nil issues pt.

Is anybody able to provide a sequence that fills in the gaps? Ahem, I'm aware of what needs to go in the gaps - its just I'd like it defined by somebody who is very knowledgable in this area. Any help is greatly appreciated.

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2 Articles; 11,114 Posts; 14,407 Profile Views

I'm not sure that what you think you want exists as a codified entity. Many of us charted with a top-to-bottom review of systems-- pt's subjective stmts if any, neuro, psychosocial, special senses, cardiovasc, resp, GI, GU/repro, ortho, skin, activity, with labs/vs/diagnostic imaging findings/consults where they fit in, and plan. Is that what you meant? Or are you looking for a historical artifact for some sort of paper? Florence's classic "Nursing: What it is and what it is not" might have what you seek. Help us out here.

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55 Posts; 3,515 Profile Views

Some hospitals have a system which everyone follows (in Sydney, Australia). Some places everybody has their own system for writing notes. The notes format I want has been demonstrated by a few nurses I have had contact with. It's specific......it's set out in a certain way. It's not the top to bottom method.

The format that was nicely written out for me has unfortunately been lost. Personally, I blame the wife :)

I can't tell you exactly how it is but I'll know when I see it.

It begins mentation, observations, in/out then something something something in a specific order. Agh!

Its like trying to find the grail now.

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JBudd has 38 years experience as a MSN and specializes in trauma, teaching.

2 Followers; 1 Article; 3,746 Posts; 35,598 Profile Views

Are you thinking of SOAP notes?

Subjective data, Objective, Assessments and Plans

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eatmysoxRN has 1 years experience as a ASN, RN and specializes in Med/Surg,Cardiac.

728 Posts; 8,588 Profile Views

In addition to the assessment which is separate from notes in my facility, I always write a note specific to diagnosis. If they came in with chest pain, I'll write "pt c/o cp x1. Relieved with 1 nitro per order, see MAR. BP 144/82. HR 90 NSR. RR 18 even and unflavored, patient denies shortness of breath. S1S2 heart sounds noted. Pedal pulses 2+...." the most important thing to me is to paint a picture of relevant findings. If bowel sounds fro. I 2 days ago are needed, I'll refer to previously charted assessments. I only note about data that isn't in an assessment or that I want the doc to know.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

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liveyourlife747 specializes in Home Health/PD.

227 Posts; 5,270 Profile Views

In addition to the assessment which is separate from notes in my facility, I always write a note specific to diagnosis. If they came in with chest pain, I'll write "pt c/o cp x1. Relieved with 1 nitro per order, see MAR. BP 144/82. HR 90 NSR. RR 18 even and unflavored, patient denies shortness of breath. S1S2 heart sounds noted. Pedal pulses 2+...." the most important thing to me is to paint a picture of relevant findings. If bowel sounds fro. I 2 days ago are needed, I'll refer to previously charted assessments. I only note about data that isn't in an assessment or that I want the doc to know.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

"Unflavored" respirations! Lol. Gotta love the typos

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eatmysoxRN has 1 years experience as a ASN, RN and specializes in Med/Surg,Cardiac.

728 Posts; 8,588 Profile Views

"Unflavored" respirations! Lol. Gotta love the typos

Hahaha! Predictive text will be the death of me.

~ No One Can Make You Feel Inferior Without Your Consent -Eleanor Roosevelt ~

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