Nursing notes are usually a specific set of health records, accurately documenting several medical assessments of a patient by a nurse. These assessments often incorporate documentation of information such as changes in a patient’s condition, their vitals, type of care provided, among others. Thus, this information entails a detailed report of the medical examination process conducted and filled out by the associated nurse. Therefore, nursing notes templates are pre-designed forms readily available online or downloaded and filled out by the nurse’s assessment notes.
These notes are usually essential as they support and provide the other associated healthcare practitioners with the relevant data for exemplary treatment and healthcare delivery. Thus, these templates negate the tedious and time-consuming fresh creation of nursing notes as the nurses will only be filling in blank spots on a template.
What to Include In These Nursing Notes Templates
Nursing notes should always include certain sets of information to qualify as standard and recognized by all medical practitioners. Therefore some of the essential information to be included are;
Patient’s Identification Information. This includes the patient’s full name and several other optional data such as age, weight, height, among others, to ensure that there is no confusion or mix up when the notes are forwarded to the clinicians.
Time. This entails the arrival and departure times of the specific patients. This is to show the extent of the patient’s stay in the said health facility as this is also vital in other medical considerations.
Patient’s Comprehensive Assessment. These include a set of several clinical measurements indicating the state of an individual’s/patient’s vital body systems and functions either physically, psychologically, or physiologically. They henceforth include information on a patient’s;
Vital Signs Notes
- Body Temperature
- Respiration rate
- Pulse rate
- Blood pressure
Physical Assessment Notes
- HEENT (head, ears, eyes, nose, and throat)
- Lymph Nodes
- Motor activity
Pain Assessment Notes
- Pain or No Pain
- Intensity on a scale of 1-10
Medications Taken Notes
Skilled Nursing Care Performed/Provided
Additional clinical findings
New Identified problems/goals
Universal precautions followed
Care coordination process
HHA, MSW Discussion Notes
Physician contact Discussion Notes
Previous Treatment Discussion Notes
These are just but some of the information included in this section of the nursing notes to give it a comprehensive and acceptable look among health care professionals.
This entails the associated nurse’s personal information, such as their full names and signature. This should be added at the end of each assessment entry to ascertain the assessment.
Assessment Entry Time
This should also be included in the nursing notes at the end of each entry. Thus, the nurse should always indicate the exact date and time they made the entry to prevent future confusion.
Tips on Writing Perfect Nursing Notes
Using a consistent format with the overall health care system will improve comprehension by other associated practitioners, resulting in a perfect nursing note. Nonetheless, there are certain key points worth noting and adhering to when planning on perfecting your nursing notes. They include;
- Timely Writing. The nursing notes should always be filled out before much time passes, preferably within a maximum of 12 to 24 hours. This is to minimize the possibility of forgetting certain details while also availing the notes to the clinicians doing rounds or the next shift nurses to prevent inconveniences in a hospital/caregiving facility as this could be fatally dangerous.
You should thus try and write the notes during the medical evaluation as you proceed. This will help with timely writing and the possible forgetting as the information will be fresh.
- Write Eligibly. This is also an important key point. Therefore, your nursing notes should always be properly organized and clear for easy reading by any complacent healthcare provider. Thus, always try and write as clearly and neatly as possible.
- Keep Your Notes Short and Relevant. These nursing notes are usually for quick perusing by associated individuals and thus should always be short and to the point. You should subsequently avoid long, unnecessary, and irrelevant information with no clear relation to the current patient’s health condition.
- Avoid Abbreviations. Always try and write down all the information collected fully and avoid abbreviations if necessary unless internationally recognized. This is vital because clinicians may use these notes in other facilities where certain abbreviations may mean different things, thus complicating the treatment process.
- Write Down All Communications. It is important to write every relevant information regarding the patient’s health without omission of any information. These should include even the information sources during your discussions and their names, too, for possible future references.