Nursing Note Suggestions...

Hello everyone! I'm starting my second semester of my nursing program this Monday. I'm trying to brush up on some things before hand... Does anyone have some hints on writing nursing notes when you chart?? My class didn't do too much of them and I think I'm going to have to learn to do them soon!!

:rolleyes:

[francine79]

make sure they aren't biased. Don't write statements like....pt. is a lovely person. it's not necessary and doesn't pertain to their care, not only that, it's your opinion. Where I work, I see alot of CNA's that are nursing students writing things like that on the charts. Use subjective statements if you can.

Try to make them simple and to the point. and use the organizations approved abbreviations when possible.

I don't really know what else to say. You pretty much chart what you are doing to the patient and the patients response to care.

[Carolanne]

Good advice above from Francine, record the important stuff and anything out of the ordinary that happens. Don't forget to keep up with progress on wounds after you have changed a dressing, etc. - i.e. "dressing changed to sacral decubitus. Small amount of yellow purulent discharge noted with surrounding erythema."