when to write a nurses note?

[garyg]

Hi, I am a brand new LPN, (3 days on the job) I am a little unsure of when to write a nurses note. There are a few residents that a note must be written daily, but besides that, what constitutes need to write a note. Thanks in advance, Gary

[CoffeeRTC, BSN, RN]

Please see your facility P and P. In general, when in doubt document it. It never hurts. We chart on all pts on medicare list, new admits, readmits, incidents, res on antiboitics, any new orders, any issues with family, any behavior changes, and refusal of meds or food.......

[TheCommuter, BSN, RN]

I assume that you work in a nursing home or some sort of LTCF. You might want to make an entry in the nurses notes for these situations:

1. New orders

2. Falls

3. Skin tears

4. Bruises

5. Aberrant behavior

6. Admissions

7. Discharges

8. Sending a pt. out to the hospital

9. Whenever a pt. goes out on pass

10. Refusals to take meds, showers, or treatments

11. Antibiotic charting

12. Medicare charting

13. Always document when giving an initial dose of a med

14. Always document when you call a physician regarding a pt.

15. Always document that you notified the responsible party of new orders, bruises, skin tears, falls, or any change in condition

16. Fighting with roommates

17. Response to an initial dose (no adverse reactions, etc.).

18. Appointments

19. Document if a resident is seem by the doctor during rounds

[Ruthiegal]

From Nursing School long ago! An instructor said "Please remember, On the Seventh Day God Charted!" remember also if it wasn't charted it wasn't done! :)

[CaLLaCoDe, BSN, RN]

From Nursing School long ago! An instructor said "Please remember, On the Seventh Day God Charted!" remember also if it wasn't charted it wasn't done! :)

Yeah, that's me, charting late again! No, I'm definitely not a god!

Cool list Commuter! I doubt I was given this list in school; it would have proven invaluable; too bad I had to learn it the hard way!

[CoffeeRTC, BSN, RN]

Also wanted to mention you should talk to your RNAC or MDS person. They will have a list of items that you should include in your note for certain things so that they have support when doing the MDS.

[scoochy]

Great job, "The Commuter!" Just want to add one to your list: pain issues.

[NurseKatie08, MSN]

The Commuter supplied a great list. I work on the sub acute wing in a LTCF. I'm responsible for 9 beds (four semi private & one private room) each time I work (M-F 3-11) Medicare notes are required daily at my facility, and are split up between shifts. I write medicare notes on 4/9 beds and the day nurse writes on the other 5. Additionally, we must chart q shift on anyone taking antibiotics, chart if we give a PRN med, if a BP med was held per parameters, if a med was refused, new orders, new admission, discharge or if some sort of event happens with the patient. Since my sub acute people always seem to have issues going on, I end up charting on almost all of them.

[CaLLaCoDe, BSN, RN]

20. Pain

**21. Patient's time of departure to a procedure or diagnostic (in hospital or at an offsite clinic) and status; time of return and status.

22. IV placement and removal.

**I always forget to do this ONE!

[kmarie724]

Good list so far. A good rule of thumb my DON gave us is: "If it's important enough that you mention it in report for the next shift, then you should make a nursing note one it."

[SuesquatchRN, BSN, RN]

23. LAST dose of an abx.

24. ANY change in status.

25. Any patient complaint that required a nursing intervention, right down to taking a temop.

26. Any PRN meds given.

[garyg]

Thanks everyone, I am new to nursing as well as allnurses.com and I can see already that this will be a valuable tool! Starting my nursing career is even more challenging than I thought it would be and having the support is great! Thanks again. garyg