Nursing Notes

I'm a huge believer in not over-documenting. If it's in my assessment (or documented any other accessible place), you won't find it in my narrative note.

Agree with pangea, my note only contains that which can't be clicked.

I used to struggle too until I realised the easiest way is make sure you have the same structure for each note. Body systems/head to toe is good to use I think. You mention all the systems but you don't need to go into detail about all of them unless something happens or is important for oncoming staff to know. My notes follow this structure of head to toe:

Neuro: are they alert and orientated? Or are they confused? Head injury - include MSQ. Sedation levels.What's their pain like/what did you do for it?

cardiovascular: we're they hypo/hypertensive? Tachy? Brady? Why and what did you do for it. I also include how many cannulas they have and what fluids are running.

Respiratory: what are their sats, WOB, are they on 02.

Gastro: tolerating diet? Nausea? If so what did you do for it. BSL issues. Did they open their bowels.

Genit: do they have an IDC in? Draining okay? Or are they passing in bottle/pan. Was an MSU collected.

Skin integ: skin intact or is there a skin tear - if so what did you do for it/apply dx. 2/24 turns/reposition etc.

mobility: are they indep or do they use 4ww or are they rest in bed. How many assistance to get them up.

Social: did family visit, any issues or queries from pt.

Not every patient needs a long winded explanation of every system. I don't go into all the vital signs of cardio and resp unless they were having issues. So I might not mention their sats or BP if it's all normal. Instead I'll just say 'vital signs within acceptable parameters'.

Example below (as you see, it's a condensed version of above and I only really mention what's relevant to the pt, don't need to explain everything). Below is from a made up pt too, btw. Also, not from America so my terms used might be different.

Pt alert and orientated.

Moderate c/o pain to R) hip, PRN analgesia given as charted with good effect.

Pt hypertensive this shift, BP 178/94, STAT dose of Amlodipine given with good effect. BP 142/70 ATOR.

All other vital signs within acceptable parameters.

PIVC x 1 L) hand patent and intact.

IVABs given as charted, IVF running at 82mls/hr.

Pt vomited x 1 after eating lunch, 4mg ondansetron given with good effect. Pt currently tolerating small amounts of fluid.

IDC insitu, draining well. BNO.

Skin intact, assisting with 2/24 turns for PAC (pressure area care).

Pt SOOB for lunch with stand transfer x2 assist. Teds/SCDs insitu.

Nil other concerns voiced.

Thats how I do it anyway. Hope it helps.

All answers are correct however it really depends on where you work? If you are working in a geriatric LTC facility when, what, and how you write your notes will be almost 100% different from a nurse working in an acute care med/surg unit.

Does your job use computers? Do you have check lists nursing notes, i.e, alert and oriented times 4, (check box yes or no). Lungs clear to auscultation (check box yes or no). Nurses on the night shift's notes may really differ from the nurses notes on the day shift for the same patient.

You can get some ideas from reading what your co-workers notes say. Unfortunately you may be getting "bad" examples to follow.

Try to find your policy and procedure books, it may have some vague information about nursing notes.

It is not wrong to have a sit down with your charge nurse and ask her to go over what the facility expects nursing notes to cover.

There are even medical/medicare "billing" requirements that affect what a nurse needs to chart so the services will be paid for.

I tend to have a basic template for my notes. At my facility, we note by exception, except ICU/Stepdown, where we note q2h.

With noting by exception, I typically have an opening note and, if I think about it, a closing note. In my opening note, I document the patient's diagnosis/reason for hospitalization, and dressings or drains in place and their status, Foley, NGT, PEG, and then what I think of as the close-up: alertness and orientation, V/S stable/guarded, bed low, side rails, call light accessible, and I always note to see assessment for any further detail.

The only time I always make sure to do a closing note is to if I float to tele because I have to note end-of-shift tele readings on all my patients.

My opening note, since I'm on a predominately post-op unit, goes along these lines:

Assumed care of [age]yo [m/f] pt of Dr [Name], S/P [Procedure], site covered with [Dressing], [any drainage/inflammation/etc noted]. [Any drains, Foley, other uniqueness if applicable]. AAOx4, VSS, bed in low position call light in reach, side rails up x2, no s/s distress. Denies needs at this time, see shift assessment for further detail, will continue to monitor.

Assuming all goes well, that may end up being my only note of the shift. If I talk to a doctor, my note included why I spoke to the doctor, and if any new orders were received:

Spoke to Dr [Name] re: [issue], new orders received and carried out. Will contribute to monitor.

I don't list the new orders in the notes because they've already been entered as orders. Avoid double-documenting as much as possible because the more you document, the more you open yourself up for error.

Anywho, hope that helps!

Try to find your policy and procedure books, it may have some vague information about nursing notes.

It is not wrong to have a sit down with your charge nurse and ask her to go over what the facility expects nursing notes to cover.

There are even medical/medicare "billing" requirements that affect what a nurse needs to chart so the services will be paid for.

I do private duty nursing through three different agencies, and each agency has different charting requirements. The same is true on different hospital units.

In home care, the nurse must chart every hour, to show the insurance company that the nurse is actually needed every hour. We also have to chart about pain every two hours; I have one agency that says that I have to use the word "pain" every two hours, while a different agency will accept a reference to comfort, such as "sleeping comfortably."

Also, our charting has to show that any interventions did or did not help. (If I chart that I suctioned the trach, I need to also chart whether the airway is now clear, for example.)