Nursing notes

Debbie_LPN · Jan 29, 2005

mandykal said:
As a student, I'm having difficult time writing nursing notes....It's crazy, I feel like holding both sides of my head and driving it straight to the wall!
It's been about 8 days since we started clinicals...even the most simplest thing...I can't describe...So much in hand to study....Any ideas??
KAL

We've all been there sweetie! Our one instructor told us to just write down EVERYTHING you do. But that didn't fly with another instructor who told us it should be "short and sweet". If you talk to your instructors, i'm sure they will be happy to help you--that way there you can see the style that they prefer. Good Luck!! ?

meownsmile, BSN, RN · Jan 29, 2005

Short and sweet is best. Use direct language.

Old RLQ dressing removed, dried drainage noted. Area cleansed with ______, incision edges well approximated and staples intact without redness or active drainage. New ______ dressing applied and secured with _____tape.

Covet · Sep 26, 2007

What book can I buy to improve or better my nursing notes any suggestions will be greatly appreciated.Thanks!!

Daytonite, BSN, RN · Sep 26, 2007

See this recent thread on narrative charting:

BandidoRN · Jan 25, 2008

Ok, I can understand the frustration that you were feeling because now is my turn! Im a student nurse in a similar situation. But in my case I just happened to be a esl student (english as a second language).

As a esl student is so hard to content my teacher because nurses have a very specific vocabulary that they use. And anything different or less descriptive is just unacceptable.

Did you find a good book that help c your narrative notes?

Any tips that u can give me?

Any help will be highly appreciated.

Thanks

shauntaebrit · Jan 26, 2008

I am in med-surg right now so taking notes is a must. What I do is I write down what I feel is important and that is basically something the instructor would repeat many times and i would also research it to get a better understanding. One intructor told to basically walk with books and notes attached to your hand.

CABG patch kid, BSN, RN · Jan 26, 2008

I'm not sure if your teacher approves of this, but I had many teachers who let me write a rough draft on scratch paper first before writing it in pen on the patient record. I am quite horrible at making some stupid mistaks on the flowsheet, and then making an even bigger mess when correcting it

Now as a graduate nurse, I am fearing the nursing notes all over again! LOL, overcome one obstacle (school) for many new ones. But its worth it guys!

LFrieds · May 12, 2012

Hi all, I am new here an just browsing. I'm the Staff development coordinator and ADNS at a SKilled Nursing and LTC facility. I hope this helps someone. I know it helps my nurses.

Skilled Admission Note Highlights: EXAMPLE

1. Resident admitted to rm#___, time, from what facility, via _______ (? ambulance), # of attendants, transfer by #____ from stretcher to bed, with _______ (extensive/limited/ supervision) assist of #___.

2. Resident requires daily skilled nursing level of care R/T Dx of : list primary Dx’s

3. Mental status ie. A+Ox3

4. Mood ie. Pleasant and cooperative

5. Neuro status ie. PERLA

6. Assessment of any relative organ systems

7. VS and O2 sat: on room air or oxygen. Oxygen via _______at ____L/m

8. Bladder and bowel continence, voided?

9. Bowel sounds, condition of abdomen ie soft, Last BM

10. Appetite: ie. Ate 50%, ability to feed self

11. Pain, note level on scale of 0-10, meds given and effectiveness

12. All skin and Wounds issues: size, drainage, surround skin, wound bed, location, type, treatment

13. Weight bearing status

14. # of assist(extensive/limited/ supervision) with bed mobility and transfers

15. Lung sounds

16. Participation with therapy: PT/OT/ST

17. Does resident have a DPAOHC? Copy obtained? Document your referral to SS if needed.

18. Code status

19. 2-1/2 side rails as enablers for bed mobility

20. Oriented to call light and room

21. Orders to pharmacy

22. Sign note

Daily Skilled Note Highlights: EXAMPLE

1. Resident requires daily skilled nursing level of care R/T Dx of : list primary Dx’s

2. Mental status ie. A+Ox3

3. Mood ie. Pleasant and cooperative

4. New orders

5. Assessment of any relative organ systems (see BLUE skilled charting guidelines page at front of IDT notes for each note)

6. VS and O2 sat: on room air or oxygen. Oxygen via _______at ____L/m

7. Appetite: ie. Ate 50%, ability to feed self

8. Pain, note level on scale of 0-5, meds given and effectiveness

9. All skin and Wounds issues: size, drainage, surround skin, wound bed, location, type, treatment

10. # of assist(extensive/limited/ supervision) with bed mobility and transfers

11. Any changes in status and your response, ie. Called MD etc

12. Participation with therapy: PT/OT/ST

13. Sign note

3/25/10LF

Double-Helix, BSN, RN · May 12, 2012

How are so many old threads being dragged up lately? This thread is from 2007 and last reply was 2008. All the posters have graduated nursing school by now.

Mama_Cashew, ASN, RN · May 12, 2012

Ashley, PICU RN said:
How are so many old threads being dragged up lately? This thread is from 2007 and last reply was 2008. All the posters have graduated nursing school by now.

Because when someone asks a question they get told to search because their question has been asked before!

Double-Helix, BSN, RN · May 12, 2012

Mama_Cashew said:
Because when someone asks a question they get told to search because their question has been asked before!

Yes, sometimes, especially if it's asked frequently. However, the person that dragged this thread up (and other posters in other ghost threads) aren't asking a question in the thread, they are giving advice for the original poster or commenting on posts from years ago.

Such as in this thread- the response that brought it back was a "staff development person" sharing her information regarding how to write a nurse's note.

Just read the dates, people! If it's from years ago, it's okay to start your own post. If there are several threads like yours in the past few weeks, just add to one of those threads.