Nursing Notes??

Esme12, ASN, BSN, RN · Sep 8, 2012

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Narrative charting is a straightforward chronological account of the patient's status, the nursing interventions performed, and the patient's response to those interventions. Documentation is usually included in the progress notes and is supplemented by flow sheets. The Joint Commission on Accreditation of Healthcare Organizations (now just the Joint Commission) standards require all health care facilities to set policies on how frequently patients should be assessed. Document patient assessments as often as your institution requires and more frequently when you observe any of the following:

change in the patient's condition
patient's response to a treatment or medication
lack of improvement in the patient's condition
patient's or family member's response to teaching

Document exactly what you hear, observe, inspect, do , or teach. Include as much specific, descriptive information as possible. always document how your patient responds to care, treatments, and medications and his progress toward the desired outcome. Also include notification to the physician for changes that have occurred. Document this communication, the physician's response, new orders that are followed, and the patient's response.

You can organize your notes by using a head-to-toe approach or by referring to the care plan and documenting the patient's progress in relation to the plan and any unresolved problems. Regardless of the way you organize your narrative note, be specific and document chronologically, recording exact times."

Dos and Don'ts of Nursing Documentation

From A contributor that has been dear to this forum.....Daytonite (RIP)

when i was working i used to make sure i had copied all the doctors orders for labs, diet and treatment onto my "brains" (report sheet). when i charted, i generally started out by writing my head to toe physical assessment of the patient followed by attention to the various doctors orders and how they were being carried out. as i got more experienced i was able to include some of that with the physical assessment as i was writing it up. i always charted observation of iv sites, any tubes or drains and the amount and color of what was draining out of them, dressings or incisions and the amount and color of any drainage, if the patient was getting oxygen, the patients activity (walking, ambulated with one or two assistants, being turned, sitting up in a chair, had no movement on one side of the body as in stroke patients, sleeping) and how they were accomplishing their toileting. any major problems that you know the patient to have should be addressed as factually as you can write them. and, factuality is usually the challenge of documentation. some words just include our own bias and we have to be careful of that. you will find that over time you will develop a regular way of charting, a format of your own, that you won't deviate that much from. this is a career long evolution. you can also download and use the student clinical report sheet for one patient that is attached at the end of this post to help you with organizing a head to toe assessment.

Critical Thinking Flow Sheet for Nursing Students

Student Clinical Report Sheet for one patient

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