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

[scoochy]

This is a great thread..really got everyone going, and IMO gave great answers to not only the "threader," but also was a great review for me! I am going to share this one with my co-workers!

[brown eyed girl]

IF IT SEEMS IMPORTANT TO YOU OR YOU WANT TO BE ABLE TO REFER BACK TO IT, CHART IT! You never know when your charting will come in handy. I was once told a few months back that there was an issue with a resident and the state was likely to get involved; whatever it was about, I was the only Nurse who'd documented the issue repeatedly and it saved the facility from a bunch of extra foolishness because they had a leg to stand on. Also, when you document, get straight to the point; ex. The patient's U/A C&S returned and showed a +3 bacteria. It goes like this: U/A C&S returned, +3 bacteria noted, Physician notified, new order for Levaquin 500mg po qd x's 7 days ordered, first dose initiated (ALWAYS, ALWAYS, ALWAYS INITATE THE FIRST DOSE IF YOU GOT THE ORDER), no adverse reactions noted. 99.6-84-20-126/74. Standing order for acetaminophen 325mg, 2 tabs po q6h PRN x's 48 hrs initiated due to resident's noted elevated temp; medication noted effective after approximately 1 hour, temp noted 98.4. RP successfully notified at xxx-xxxx and made aware of new orders and resident current status. Resident is noted without distress and will be continually monitored.

Make sure that you ALWAYS document that the family was notified; leaving a voicemail IS NOT NOTIFICATION!; You must NEVER leave any medical info on that message; just identify yourself (so they know who to ask for), who the message is for, let them know that it IS NOT an emergency, and that you want to make them aware of a care update PERIOD. Also, if the resident is listed as his/her own responsible party, CHART IT IN YOUR NOTE; if the resident is clearly confused and you know that they wont remember, call the next of kin and let them know AND CHART THAT TOO! Always chart so that it lessens the need for management to ask questions; most if not all of their questions should be answered in YOUR NOTE. And also chart as if you expect the State to look at your note, trust me it works. I've had to talk to a state surveyor on more than one occasion for an issue with a resident and I always somehow had to read my note (just happened to be during the time that I worked with the resident) and I have always gotten an accolade from the surveyor about my note, which takes the focus off of me and lessens the questions that I have to answer plus, management wont be looking at you to find out why you didnt do such and such.

If you have any other questions about documentation or anything else, please feel free to PM me and I will help you gladly! OH, by the way, WELCOME TO NURSING AND WELCOME TO ALLNURSES!

[meadowsong, ASN, RN]

When in doubt, write it out. Your better off over documenting than missing information you should have put in there.

[kmarie724]

^

Agree

[keriparis]

Brown eyed girl...thanks for the info...I need your help with charting but its difficult to pm you

[CapeCodMermaid, RN]

We chart PRN meds on the MAR so no need to write a note about it. We chart refusals on the MAR so, again, no need to write a note about it. We have enough to do without double documentation. We describe the wounds on the TAR so no need to include that in a note. We do chart any incident or change in status, admissions,discharges,and transfers to the hospital or to another unit in the same building.

[tsm007]

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

This was incredibly helpful. Yes, I have spent the entire night scouring AN for charting help and have created a huge template for myself. I know this is old, but I also know you are still around. So BIG HUGE THANK YOU for this post and others and being one of those nurses who are willing to teach.