nursing notes

anyone?

i always say C Y A

I had to think about that for a moment. CYA...in what sense, and how?

I am a fairly new grad...I struggle with nursing notes. I tend to write a 'status' report DIAP) which includes a general overview-- and sometimes long, rather than a simple focus note.

Also, I have sometimes written things, then later, at home, thought to myself, that was a stupid thing to write.

For example, today I am obsessing over the fact that I wrote about a pt's BP of 90's/40's, with a 0400 bp of 87/46, rechecked 5 mins later at 92/46, and a call to the on call MD about the pt's 'hypotension'. So now I am mad at myself for labeling this 'hypostension', as I dont want to label like that....dumb!!

Any tips on writing notes?

You sound like a very conscientious person, don't worry too much about "sounding dumb".

I think it is ok to write hypotension but, I would usually write something like "decreased BP" if I was charting. If someone has low bp I also do a focused assessment, ask them if they are dizzy, what they normally run at etc. That can sometimes give a better picture of what is going on with the pt. A pt with a BP of 90's/40's whom is dizzy, has minimal I/O and usually runs in the 140's/70's is very different from a pt with a BP of 90's/40's who denies sx and usually runs 100's/50's.

If something were to happen to the pt, writing too little is what is really going to come back to bite you. You mentioned you are still new so it will take some time but, try to be as brief and concise as possible while still including all pertinent information. Sometimes doing this will make it impossible to be brief.

When I started umpteen years ago, I would write what I wanted to say on another piece of paper. This way I could make sure I was including everything I wanted to say and getting everything pertinent down in the note. When I was satisfied I would write it into the nurses notes.

I have given other new nurses this advice and it has worked for them as well. Soon enough you will be writing notes like a pro. But definitely always CYA.

what was wrong with writing "hypotension"?because the systolic was over 90?