What do I chart on the Nursing notes???

It depends on what your note is for. Is it to address the care plan, is it a note to acknowledge you recieved a patient from ER or PACU? Is it a note regarding a call to the physician? It really makes a big difference as to how much and what you would chart.

A note at recieving a patient would include everything regarding the patient status at the time. Foley, IV sites, fluids running, pain level, any distress, oxygen in place, vitals, any dressings incisions or sutures and their condition and status of any drainage, if family is present.

A care plan note technically only needs to address the plan of care. However, after addressing the plan, i always include kind of a patient status and small summary of the patients day including ambulation, how they tolerated PO, voiding, vitals, and address if safety measures are in place such as bed in low position, call light within reach and then i comment regarding any injuries or lack of for that shift. I may include whether a dressing change was completed, how well the patients mobility is whether they need 1 or 2 for assist to transfer, etc.