Nurses Notes.

[StudentOfHealing]

Is there an official name for nurses notes that are short, sweet, and direct to the point. My instructor likes short direct notes. No narrative or story telling. No saying "I" or "patient/pt". I just want to know the name of these type of notes ... just like long illustrious notes are called narrative notes, what are these called. I want to improve my nurses notes by searching for example.

My instructor explained to us a couple of times but I don't seem to understand.

For example she said that when we walk in to assess the bed rails, low bed vs high bed. saline lock vs running IV. What is running? at what rate. With what pump? Are they A&O? Respiratory rate? any pain?

The following is made up...

0834: A&O X 3. Low bed. 3 rails up. 1 rail down. warm & dry to touch. saline lock @ left antecubital aspect, no inflammation, rubor, or infiltration. Abdominal Pain 5/10.

U/O @ 40mL. 50% meal completed.

Is this good?

Thanks

[nurseprnRN, BSN, RN]

If that's all she wants, that's what you give her.

I would have expanded on it so my reader down the line would have a clearer idea and image of what this patient was all about, but hey.