nursing notes

vintagemother, BSN, CNA, LVN, RN · Jan 30, 2015

Adpie, soap, soapie are acronyms used to organize your nursing notes

Google these on AN. I'm in a meeting right now so I can't write it all out right now.

Here's a link:

https://allnurses.com/general-nursing-discussion/whats-the-difference-402850-page2.html

vanilla bean · Jan 30, 2015

Also, if/when you have downtime with your assigned patient(s), read through the notes that the nurses have written when they cared for the patient(s). It will help familiarize you with format used by the facility where you are doing your clinicals, and appropriate terminology and content.

RN403, BSN, RN · Jan 30, 2015

Think head to toe. Start from the head (awake, alert, oriented, etc) and work your way down! Keep a cheat sheet with you...as time goes on you will write your notes with ease.

soranaruto · Jan 30, 2015

Also, if/when you have downtime with your assigned patient(s), read through the notes that the nurses have written when they cared for the patient(s). It will help familiarize you with format used by the facility where you are doing your clinicals, and appropriate terminology and content.

I get it but we don't start "clinicals" until we know how to write an assessment/nursing notes so, I wont have any nurse to assist me other than my professor.

vintagemother, BSN, CNA, LVN, RN · Feb 1, 2015

Im nursing school we learned to write nursing notes based on a full head to Toe assessment.

In real life, as a nurse, we tend to write more notes based on a specific problem.

If you include the following in a nursing note, you'll probably be headed on the right track.

1) objective data

2) subjective data as it relates to the problem

3) your nursing intervention

4) the Pts response

Some nursing notes are simply on the Clients progress toward achieving certain goals as defined by the care plan.

It took me awhile working before I became more confident in my nursing notes/charting.

I second the idea the OP had about looking at other nurses notes.

Once working, I also used cheat sheets provided by other nurses or my facility on what to chart. For example, admission and discharge summaries have to include certain information specific to the discharge/admission.

vanilla bean · Feb 1, 2015

I get it but we don't start "clinicals" until we know how to write an assessment/nursing notes so, I wont have any nurse to assist me other than my professor.

Many of us here are happy to help, but please provide a little more information. What direction has your program given you so far? Is there a particular format they would like you to use (DAR, SOAP, etc.)? The only think we know for sure that you had trouble with was not using medical terminology in your previous notes. Can you be more specific about what's tripping you up? It will help us guide our responses to help you.

soranaruto · Feb 6, 2015

we're using the head -toe assessment. I'm struggling to state the effects of the condition.

For example: Cyanosis: Blue discoloration. what if there is no Cyanosis? My professor doesn't want me to write "normal" or "no bluish discoloration." What can I write as a replacement?

firefly84 · Feb 6, 2015

Write what you see; what colors, is the skin dry, chapped, cracked, bleeding...

Write what you hear; stridor, audible wheezes, coughing (harsh, tight, loose)

Write what you smell; breath is sweet,

Write what you feel; perhaps someone has crepitus,

Use your eyes, ears, nose, and hands. You have a full assessment kit built in. Do this for your entire head to toe assessment and you will end up with plenty of details.

Go online and just do a search for complete head to toe assessment examples and you should find a lot of good info.

quixotic.dy · Feb 8, 2015

I am struggling to write nursing notes. Any tips? are there any common mistakes that I should avoid? I didn't use medical terminology in my notes. is there any acronym to simplify the concept?
Just a basics student, (2nd week)

I understand where you are coming from. I am first semester and there's been little direction in my health assessment class.

It's also difficult when not allowed to use the word normal or no.

The tips we were given is saying things like "patient/client denies..."

Or using the abnormal results and saying that is not noted.

I also bought a nursing diagnosis book and that really helps with the assessment and plan part of the soap notes on your healthy nursing student lab partner.

I think it all kinda just clicked yesterday which is good because I felt like i was drowning last week (only week 2 but it doesn't take long to be behind).

Subjective is just a recap of the health history at this point. Later it would include a quote of why the patient is there.

Objective is everything you see. That's your "skin is warm and dry. color is pinkish tan with darker pigmentation in sun exposed areas. Turgor good. No suspicious nevi noted. Nails are smooth, translucent, and attached at the nail bed. Capillary refill less than 2 seconds"

Assessment: at risk for impaired skin integrity due to radiation damage from excessive sun exposure.

Plan: student nurse will teach client how to do a skin self examination.

Student nurse will teach client importance of sunscreen use and risks of sun exposure.

Client will report any changes in lesions immediately to provider.

Student nurse will continue to monitor.

Just hang in there and talk to other in your cohort. They are all feeling the same way I am sure. Also if you can make friends with any one a semester or 2 ahead they are great resources and usually willing to help because they remembered when someone helped them.

Hang in there.