Nurses Notes(What do I write??)

[Forever Sunshine, ASN, RN]

Ok I am starting to get down WHEN to write a nurses note. But when I have to write a nurses note... I feel like I don't know what the hell to write lol. What are important details to mention in a nurses note?

[cakegirl]

You would write a summary of the patient on your shift. If a new admit, how are they adjusting. I's & O's. Vital signs or skin issues if present. Did they refuse meds. If changes in behavior a detail description, ie combative with staff, what was your intervention & what was the outcome. If a pt refuses AM or PM care. In my facility we note if someone has vomiting or large loose stools X how many. Since it's longterm care we also note anytime someone recieves a prn & why and of course the effect. Basically you are painting a short specific picture so if someone else reads it they will know exactly what happened. When I first started I used to write my notes out first on scrap paper & reread it. That way you tend to catch whatever you may have forgotten & can rewrite it so it flows better. My first note I wrote about a resident falling was so bad it was allover the place, because I kept thinking of other things I should have included & I didn't use scrap paper first. Just take your time and read your own notes from throughout your shift and pick out what relevent info you wrote down and then include the current condition at the end of your shift ie resting comfortably in bed, or will f/u with PCP in the AM. Hope this helps!:)

[livelaughlove29]

Isn't allnurses.com for this exact reason? Helping other nurses out? If your not going to give advice what is the point of even commenting?????? Just curious.

I was always told not to write in nurses notes what you chart in your assessment because that is double charting...so I write somewhat of a narrative of what the patient has told me or what exactly the patient is doing or not doing or I chart more indepth and detailed information about the assessment that wasn't available to me in the actual assessment form. For instance...if you go to check in on your patient and she is sleeping quietly chart "Patient is resting with eyes closed, RR even and unlabored. Patient does not appear to be in any distress at this time and she is easily aroused. OR Patient is talkative this am. She appears to be in good spirits voices understanding about her care plan and discharge plans...education was provided about...." Or events that lead up to a certain set back the patient had in her care of health. I am sure there is more... I am a new nurse myself ~ hopefully some seasoned nurses can give you better or more advice. :)

P.S ask your facility if there is a class in nursing charting that you can take. I know that a few nurses where I work took a similar course and found it helpful!

Goodluck!

[Forever Sunshine, ASN, RN]

I don't feel that documentation was one of my nursing schools strong lessons that they enforced. I feel very weak in this area as a new nurse. I am looking for help to strengthen my nurses notes.

[NurseLoveJoy88, ASN, RN]

I agree with livelovelaugh. There have been an increased of rude posts in response to people asking questions. geeesh

Anyway, OP you want to make sure you just state the facts in your note. Including assessment, interventions, and etc.

[Forever Sunshine, ASN, RN]

After I left work last night I remembered all these things that I should have included in the nurses notes I wrote that evening. Next time I will try writing out my notes in my notebook first and add as the shift goes on.

[dscrn]

Anyone remember SOAP notes...then SOAPIER?////

[OldMareLPN]

I suggest a book like MOSBY'S Surefire Documentation, How, What and When Nurses Need to Document. I have edition two and still reread it.

You will develop your own style, until then make yourself some outline to follow, or keep notes while you work so you don't forget three hours later. If you read others notes, you will probably see a pattern (good or bad) that people use.

You are correct to be concerned, as 'not documentated = not done'. I know of a case where lack of documentation caused a nurse to lose their license, very sad.

Of course, remember there is a way to document, after the fact. You need to determine how your facility want it formatted and submitted.

Also remember to develop a understanding of what not to document, which is also important.

Good luck and keep plugging...

[MERRYWIDOW46]

We have an electronic medical record. We write A-PIE notes related to a patient problem in the plan of care and link it to our assessment.

Problem: Altered Mental Status

Assessment: Patient oriented only to self. Very lethargic, responds to deep pain and sternal rub only. Speaking in garbled and incomprehensible manner. Pulling at medical devices. 1:1 sitter present for safety. Left Hand mitt on, not tied, and on to prevent pulling medical devices.

Plan: Patient will be reoriented with each encounter.

Evaluation: Continue to monitor patient and report status changes to MD. Patient condition has not changed.

This is just an example. Good Luck.

[Forever Sunshine, ASN, RN]

I suggest a book like MOSBY'S Surefire Documentation, How, What and When Nurses Need to Document. I have edition two and still reread it.

You will develop your own style, until then make yourself some outline to follow, or keep notes while you work so you don't forget three hours later. If you read others notes, you will probably see a pattern (good or bad) that people use.

You are correct to be concerned, as 'not documentated = not done'. I know of a case where lack of documentation caused a nurse to lose their license, very sad.

Of course, remember there is a way to document, after the fact. You need to determine how your facility want it formatted and submitted.

Also remember to develop a understanding of what not to document, which is also important.

Good luck and keep plugging...

Ordered via amazon.com. 1 day shipping. Expected delivery 5/11/10 3pm. Will continue to monitor.

I tried to write that in a nurses note style lol.

[FLArn]

Also F.Y.I. if you include the phrase "will continue to monitor" you are committing yourself to at last one more entry to report what if any changes occurred in the patient and what if any interventions you did and the outcomes thereof. If will continue to monitor is your last entry then you have committed the nurse who relieves you to the above .

[Nurse_Tricia, LPN]

I too don't feel as though schooling prepared me for charting. I asked my workplace to provide me some information.. They had me sit with mds who stated at the begining of the nurses notes she has a paper on everyone who needs to be charted on and what aspect to document on other than change of condition, etc. Needless to say I have only seen 1 pink sheet and it says chart on the condition of her skin on her butt. I have sat after work after I clocked out and read many many nurses notes. There are some I get great ideas from and love the way the chart. And can relate because they are charting on residents and their conditions I am familiar with. I came across a nurse over the weekend I thought did excellent charting so I jotted some of her sentences down as it would pertain to my residents. Good luck!!