Nursing progress notes

[LilMissAlwaysCurious]

Do you make a progress note for each patient? I've seen some nurses do a "shift summary"

[Esme12, ASN, BSN, RN]

What are you referring to? You must document on every patient every shift

[psu_213, BSN, RN]

It depends on the setting. For example, where I worked at as aide in LTC the nurse had 28 residents on a given unit. Writing a not of every resident every shift was impossible. If the resident had something happen outside their norm (i.e. fall, increased confusion, fever, etc.) the nurse would write a note on that and include his/her intervention for that and chart on the outcome of that intervention.

In acute care, the policy also varies from place to place. At my first job, complete head to toe assessments had to be done (and charted) q12 hours. If, in between those assessments, there was a change in condition the nurse had to chart on that change. Most nurses did their assessments at the beginning of their shift and then wrote a note toward the end of their 12 hour shift just to summarize the condition of their patient and that their assessment was unchanged (if indeed it was).

On the telemetry floor, we had to chart a head to toe assessment every shift...sometimes they were 12 hr shift, sometimes 8 hour shift. So, some patients would have 3 assessments charted per day, others only 2. Again, notes as needed. At the same hospital, on med surg floors, where each nurse had more patients, only a focused assessment had to be done each shift. ICU nurses would have to do a head to toe assessment much more frequently.

[turnforthenurse, MSN, NP]

On my home floor (progressive care) we need to chart assessments Q4H. We do computer charting, so for the first shift assessment I chart everything and click everything that applies...for my next assessment(s), if nothing changes, I just click "no change from previous assessment." We have frequent assessment as well, where we chart the patient's activity, patient care and pain assessment, and all of those are to be charted on Q2H minimum. Vital signs are usually Q4H but I chart them Q1H. I document cardiac rhythms Q4H.

As for a progress note (or nursing note) I only chart by exception or if something new pops up and I had to notify the doctor of something, etc.

In the ER, assessments are focused based on what the patient comes in with. I make a nursing note at least Q1H, which is hospital policy, even if it's something like "patient resting quietly in bed watching TV, waiting to see MD."

[Swellz]

I've noticed that too; I'm taught in class/clinical to write a focused note on one aspect of the patient's treatment, but almost every time I look in the chart I see a note that summarized the care during the entire shift.

[SaoirseRN]

I work acute care, primarily med-surg.

I chart my morning assessments (some of this is a tick-sheet style) on every patient. I also provide "updates" through the shift. Even if the patient is not having a problem, I might say "1130 - Patient visiting with daughter. Denies pain or discomfort and has no other voiced concerns." Or "1030 - Patient reports good effect from PRN analgesic. Pain 3/10 and tolerable. Patient has no other voiced concerns."

I would do a couple of quick updates through the shift on everyone. Even just "patient has no concerns". For those who are more acutely ill/unstable/ having issues, I would chart a lot in a given shift.

I also chart every time I phone a doctor and what the results of that conversation were -- "orders received" or "no orders received at this time."

EDIT: We are still mostly paper charting.

[nurseprnRN, BSN, RN]

Homework question? Sounds like another one.

[Esme12, ASN, BSN, RN]

GrnTea you kill me..........I am sure it is a home work question but this is the homework section.....

OP you need to write a focused assessment on each patient at least once in your shift. Hospital policies determine how often and for which units. An ICU unit will require more frequent assessment than the patient on the floor. The nurses may do some on the computer or on a flow sheet so that you are only seeing the shift summary.

Ask the staff on your next clinical.

[drowningdaily]

You may not have to chart in each patient. Depends on level if care. I worked subacute where we charted new admits q shift x 5 days. After that day shift assessed and charted door beds and night shift charted window beds. If something happened or there was a change we would of course do a note.

[Esme12, ASN, BSN, RN]

GrnTea you kill me..........I am sure it is a home work question but this is the homework section.....

OP you need to write a focused assessment on each patient at least once in your shift. Hospital policies determine how often and for which units. An ICU unit will require more frequent assessment than the patient on the floor. The nurses may do some on the computer or on a flow sheet so that you are only seeing the shift summary.

Ask the staff on your next clinical.