Nurses Notes

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Does anyone know if there is a book on documenting in nurses notes? I am not good at it at all. I don't want to say too much or too little. A web site would also be helpful.

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Would love to see something too!

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Specializes in Home Health/PD.

The best way I've learned is to look at others note. You will see things you like and things you say "that shouldn't be in there." You can borrow others ideas of what to put in notes and make them your own.

At my job we have "precut" nursing notes if we want to use them. Like: orientation, behavior, and problems for the shift.

Hope that helps!

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Tyvm SuperV!!

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Specializes in Certified Med/Surg tele, and other stuff.

This book will scare the bejesus out of you, lol, but it is very good.

Guilty or Innocent? Protecting Your License Through Proper Nursing Documentation: Rosale Lobo (RN MSN LN): Amazon.com: Kindle Store

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I just bought this on iBooks!! Lets get reading!

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Specializes in LTC, Education, Management, QAPI.

there is actually a book "Charting Made Easy". you can find it at barnes and nobles, and it goes through quite a few different types of documentation. Experience, though, is the best way to learn, as is practice and making some templates on paper to remind you what to include with each note. Hope this helps! THE ISBN for this book is 1605471968 and its cheap on amazon!

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