Tips For Writing Nurses Notes

[Encephala]

Does anyone have any tips, outlines or web sites they have come across for writing good nurses notes?

I would appreciate any feedback.

Thank you.:)

[OntCaRPN]

Try looking up DAR format, I think it's a fairly often used note method.

Data:

Action:

Result:

For example .... D: pt fell

A: staff picked him up, brushed him off and reinforced teaching re using walker

R: pt safely used walker rest of shift

Now that's fairly simplistic, but you get the picture. I had trouble with it at first because I wanted to write a chronological novel about incidents :) But it works well for most things.

Hopefully you'll get more help than this.

[Encephala]

Thank you so much for your reply :). I'll do some research on that ASAP.

Try looking up DAR format, I think it's a fairly often used note method.

Data:

Action:

Result:

For example .... D: pt fell

A: staff picked him up, brushed him off and reinforced teaching re using walker

R: pt safely used walker rest of shift

Now that's fairly simplistic, but you get the picture. I had trouble with it at first because I wanted to write a chronological novel about incidents :) But it works well for most things.

Hopefully you'll get more help than this.

[suzy253, RN]

Another type of charting we've used was focus charting. Here's a link to info & example:

http://www.findarticles.com/p/articles/mi_qa3689/is_200005/ai_n8880050

[TheCommuter, BSN, RN]

Lippincott publishes a book for nurses and students regarding correct charting methods. It is entitled Charting Made Incredibly Easy, and it can be found in any major bookstore in the medical/nursing section. I have a book called Surefire Documentation, which also has some good pointers on charting. The issue of charting is very important, because it can save you from being sued after bad patient outcome and will prove the care you provided.

[Hopeslayer]

I have always charted what my head to toe assessment was, plus what they did, and any new orders, plus any other info that is pertinent to that patient. Something like.

PT alert and oriented x 3. 0 c/o pain or discomfort. skin w/d. LS clear. BS + x 4, abd soft and non-tender. +pp's. N.O. APAP 650mg po TID. PT inc of bladder x 3. 72h bowel/bladder screen started.

Something like that.

[JoAnnS]

try looking up dar format, i think it's a fairly often used note method.

data:

action:

result:

for example .... d: pt fell

a: staff picked him up, brushed him off and reinforced teaching re using walker

r: pt safely used walker rest of shift

now that's fairly simplistic, but you get the picture. i had trouble with it at first because i wanted to write a chronological novel about incidents :) but it works well for most things.

hopefully you'll get more help than this.

hello:

thank you for the tip. where exactly can i find information on the dar format?

thank you

joann:balloons: