nsg note

I'm OLD SCHOOL, so listen-up:

What is the patient's complaint(s)? (in his/her own words)

What do you see, smell, hear, touch and calculate [vital signs]?

What's your nursing diagnosis?

What's your plan of care?

What were your interventions?

Were your interventions effective and/or need further follow-up?

Sounds lengthy?

THAT'S WHAT YOU GET PAID THE BIG BUCKS FOR!

Seriously, our colleagues on this forum probably can give you a more brief, concise and updated format for a generic nursing note.

Much success in your search.

Generic note would include, at a minimum, your assessment of:

the brain

heart

lungs

abdomen

kidneys

bowel

peripheral neurovascular status

and patient's problem(s) or need(s) + and what you did about them.

any interventions / procedures

hope this is helpful. it is brief.

SPEADO

S=Skin

P=Pain

E=Elimination

A=Activity

D=Diet

O=Other........neuros, plans for dc, vitals, any further concerns or updates from the shift

In school we were taught to start with alert and oriented times whatever

(like x1, 2,or 3) and then able to make needs known or not and then chart assessed things and patient concerns. In LTC not every patient gets charted on everyday. I do peds homecare so I do chart everything about my patient. Just keep it factual and you should be fine.

At our hospital we have computerized charting. We have to perform a shift assessment by mostly "clicking boxes" etc. on every body system. We also have to write a "generic" nursing note at the beginning of our shift. This is something typical I would write.

Pt lying in bed, awake. A&Ox3. Skin warm, dry, intact. D-stat patch to R groin c/d/i. Site soft, no hematoma present, slightly tender upon palpation per pt's grimace and verbalization. Respirations even & unlabored on RA c O2 sats: 98%. Tele: SR in the 60's. IVAD: #20g to LFA dated 12/2/07, c/d/i c no s/sx of infiltration, currently infusing Integrilin at 5.3ml/hr; pt tolerating well. Denies pain, CP, SOB, dizziness, n/v at this time. VSS. NAD noted. Defer further to this RN's shift assessment. Will continue to monitor.

Hope this helps.