Need Help with Anecdotal Notes

Daytonite, BSN, RN · Oct 15, 2007

since this is something your instructor specifically wants and she has given you specific instructions, then that's what you have to give her. it sounds to me like she wants more of a kind of personal journaling as to how your clinical interaction with the patient went rather than a traditional "nurses note" that would go in a chart.

i am thinking that this may be your instructor's informal way of having you look back and analyze what you are doing during your clinical time. something else that crossed my mind is that your instructor may be getting around doing an actual process recording (ipr-interpersonal process recording) where you record a therapeutic conversation you have with a patient and then analyze your responses you made to the patient as to whether or not they were helpful and therapeutic. she's stipulated that she wants amusing anecdotes which seems a little odd to me. but, if that's what she wants, then that is what you give her since your grade depends on it.

when i was in my bsn program we had to keep a journal of our clinical experiences because our instructors often were not with us at the sites (we were already licensed rns). they were looking for the interaction that went on between us and our patients and what we felt we felt were learning from each one. we were encouraged to write down questions that our experiences generated and seek and write down the answers we found. perhaps this is what your instructor is trying to get you to do?

outside of that, there is specific information on how to chart/document on this sticky thread: https://allnurses.com/forums/f205/nursing-documentation-168921.html

simbawicz · Oct 15, 2007

Here is an example:

I admitted an elderly patient to our unit. I was going over the patient's health history, gathering information for completion of his database. He had said he was married, had kids and grandkids. Whether I was being soft-spoken, unclear, or whether the gentleman had a slight hearing deficit I don't know, but when I asked him if he was allergic to anything, he stopped talking to me and looked as if I had suddenly sprouted a second head or something. Then he asked, rather indignantly, "Am I a VIRGIN???" It was my turn to be confused and a little surprised. Realizing what he had heard, I asked, "No, I asked 'Do you have any allergies?'" We both laughed at the auditory confusion.

estuh · Feb 18, 2008

I have been writting anecdotal notes for some assignment and according to my assessor, Anecdotal notes are records of what has occured and how you responded, what you learnt and how reflection can help to improve your practice. The example she gave me is by a student:

" I showered a client and was much more organised than yesterday. I was really conscious of safety aspects because of the client's unstable gait. whilst showering the client, I noticed some broken skin on her sacrum. i informed my preceptor and together we discussed a plan of care in relation ti this problem. I reviewed current wound management in a text book. Appropriate wound management was implemented, as well as pressure area management. I administered the client's medication ensuring i performed the 5 rights. i was able to describe the action of the medication to both the Rn and the client. In the process of administering a client's digoxin, i noticed that her heart rate was 46 bpm. withheld and informed the Rn"

Hope this helps. good luck.