A nursing note is a document that contains the history, treatment, care and response of a patient while under the care of a healthcare provider This note is written by the nurse who has been observing the client and is meant to provide data for quality assurance towards expected outcome.
It is very important for the nurse to write the note in the best way possible. This can sometimes be hard to do. Using a sample-nursing note will make things clearer, simpler and easy for you.
How to write a nursing note
Don’t keep information pending
It is important to make sure that you are writing as you observe. This means that you record everything you observe immediately. Do not write your report at the end of the shift or later. Recording it immediately will give you accuracy and you will be sure of what you are saying. It will save you from making mistakes on what you write.
Make sure that the information you give is detailed by describing what happened and how you handled it.
The best way to do this is to be straight to the point. You can do this by writing a detailed summary instead of writing comprehensive information that will have so much unnecessary report. Be specific in your notes about what you observed and what you did. Because you have already documented a full assessment in other nursing documentation, you don’t need to give yourself a lot of work by duplicating all this.
Writing a summary of it will save you from a lot of work, which may somehow be unnecessary.
Do not speculate
You are dealing with the life of a person and his health. You do not want to be objective or to speculate. The best thing to do is to write down only what you have observed. Speculated information is misleading when it comes to a patient and may lead to dangerous consequences.
Write down all communication
In your time with the patient, you have had communication with the patient, the patient’s family, doctors and other health care professional. Writing this down is very vital as well as writing the names of the people involved in the discussions.
Do not use abbreviations
Use of abbreviation will most of the times be understood differently. It is important to write the whole word to avoid any misconception.
Consider the use of a scribe
This is important when handling emergency cases like cardiac arrest, trauma calls or medical emergencies. You may not be able to document the whole information in such events. In such a case, appointing a member of staff to write things as you go will help keep accurate information.
Date and Signature
Include the date and the signatures in your notes
Nursing Note Templates
Tips for Writing a Perfect Nurse Notes
- The Format – It is good to make sure that you are using a consistent format when writing your notes. The format should always include the patient’s name, the date, time and your full name.
- Be timely – If possible, write as you attend to the patient. This means that you should give fresh information. Do not wait for a long time after you have attended to the patient to start writing. the best way is to do it as soon as you have attended to the patient. Make it a habit of writing the notes after every observation. You will be sure that the information you give is accurate and nothing will be left out.
- Note down all communication – Keep in notes everything that you hear about the patient. You can hear it from the doctor or other health care provider as well as from the family members or the patient. Keep what you hear in record because it may be helpful in helping the patient recover.
- Use standard abbreviation – If you must use abbreviations, use the ones that are understood by the health care providers. Do not use any misleading abbreviations.
- Give relevant information – Stay relevant in your notes by only indicating what is related to the patient. Avoid including other information that is not related to the patient. Write only what you observe from the patient.
- Keep it simple – Write in a simple way that the nurses of the next shift will be able to read and understand to be up to speed with their work. Complicating your notes will hinder your colleagues in working because they will take time to figure out what your notes really state.
- Write clearly – This is especially if you are using handwriting. Sometimes it is hard to read a person’s handwriting. Try to write in the best way possible that will be clear to read.
- Make assessments – Make a record of any assessments that you have administered during your shift. Indicate all the information like, if there are more tests needed and probable diagnosis of the condition of the patient.
- Include all the necessary information – Keep in notes the medications that the patient has been prescribed, all the medication the patient has been given, the dosage and how the medication was administered.
- Write in standard format – This includes an opening note, middle notes and closing notes. You should also include any primary and secondary problems that a patient is experiencing. Your notes should always include records like blood pressure, heart rate among other important information that can offer insight into these issues.
Types of Nursing Note
This is a medical record that documents a detailed and well-researched patient’s status. A skilled nursing note is detailed and includes the observation and suggestions of a healthcare provider about the condition of a patient. This note involves a lot of critical thinking and professionalism when writing.
Nursing admission note
This is a medical record that documents the patient’s status [including history and physical examination findings], reason why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for the patient’s care.
Nursing progress note
This is a note into a medical or health record made by a nurse that can provide accurate reflection of nursing assessments, changes in patient conditions, care provided and relevant information to support the clinical team to deliver excellent care.
Nursing discharge note
This is a note that id used to discharge a patient from the hospital. The note reflects the reassessment and evaluation of your nursing care. It includes reason for hospitalization, significant findings, procedures and treatment provided, patient’s discharge condition, patient and family instructions and attending physician’s signature.
Nursing soap note
This is a method of documentation employed by healthcare providers to write out notes in a patient’s chart along with other common factors such as the admission notes. They include medical histories and any other document in a patient’s chart.