ItA nurse has to learn to document their patients’ conditions and care. It can be difficult as nurses to communicate with patients and their families. They also have to understand medical jargon and be able to translate it into English. To makes things simple good nursing notes examples can help any nurse hone their documentation skills. It will help the nurse to provide better care for their patients.
Table of Contents
What Is A Nursing Note?
A nursing note is a written record of a nurse’s observations and actions during care for a patient. Nursing notes are an essential part of the medical record and can help assess a patient’s condition, track their progress, and justify treatment decisions.
What are the Different Types of Nursing Notes?
There are two main types of nursing notes: progress notes and assessment notes.
- Progress: These notes are typically more concise than assessment notes. They are used to document a patient’s response to treatment and any changes in their condition. Progress notes can be written by any healthcare team member but are most often written by nurses.
- Assessment: These notes are more comprehensive and detail a patient’s initial condition and any changes over time. They are used to establish a baseline of a patient’s health and track their progress over time. Doctors or nurses typically write assessment notes.
Good Nursing Notes Examples
A nursing note example will provide an idea and basic fundamentals of effective nursing notes. Here are some nursing note samples that will help to learn the writing methodology of nursing notes.
Patient Name- Mr. Smith
Medical Record No- 12345
Date of Admission- 01/01/2020
Admitting Diagnosis- Pneumonia
Mr. Smith is a 38-year-old male who presents to the emergency department with shortness of breath and a cough. He reports that his symptoms have worsened over the past week and that he has developed a fever. His temperature is 37.8°C, his blood pressure is 120/80 mmHg, his heart rate is 100 bpm, and his respiratory rate is 24 breaths per minute. He is alert and oriented to person, place, and time. He appears to be in moderate respiratory distress and uses accessory muscles to breathe. His lungs are clear to auscultation bilaterally. He has no other significant findings on physical examination.
Patient Name- Ms. Jones
Medical Record No- 67890
Date of Admission- 01/02/2020
Admitting Diagnosis- bone fracture
Ms. Jones is a 35-year-old female who presents to the emergency department with right arm pain after a fall. She reports that she was walking when she slipped on some ice and fell onto her outstretched right arm. She feels pain in her arm and is unable to move her hand. Her temperature is 36.9°C, her blood pressure is 110/70 mmHg, her heart rate is 90 bpm, and her respiratory rate is 20 breaths per minute. She is alert and oriented to person, place, and time. On physical examination, her right arm is tender to palpation, and she has decreased range of motion in her right hand. She has no other significant findings on physical examination.
What to Include in Nursing Notes
Nursing notes should be concise and accurate. They should include enough information to provide a clear picture of the patient’s condition and progress but should not be so long that they are difficult to read or understand.
Nursing notes should be objective and free of personal bias. They should be based on the nurse’s observations and assessment of the patient, not on other healthcare team members’ opinions or the patient’s family.
- The patient’s name
- medical record number
- The nurse’s initials
- A brief description of the patient’s condition
- The patient’s response to treatment
- Any changes in the patient’s condition
- The nurse’s assessment of the patient’s condition
- Observations & Recommendation
It is always recommended to have a look at some nurse note example for getting an overview. I hope by looking at the nurses note example provided above will help to know what to include in nursing notes.
What not to Include in Nursing Notes
There are specific points that you need to make sure not to include in your nursing notes to maintain privacy and professionalism.
- The opinions of other members of the healthcare team
- The views of the patient’s family
- Personal information about the nurse
- Diagnoses or prognoses
- Speculation about the cause of the patient’s condition
Advantages and Disadvantages of Nursing Notes
There are both advantages and disadvantages to writing nursing notes.
- It helps to track the progress of patients
- Assessing the effectiveness of treatments can be helpful.
- Helps communicate between members of the healthcare team
- Can be used as legal documentation
- Takes time to write
- They Can be challenging to read if they are too long
- It Can be difficult to write if the patient’s condition is complex
- It May contain errors if the nurse is rushed
How to Use Nursing Notes in Patient Care?
Nursing notes can be used in various ways to help improve patient care. They can be used to do several things:
1. Track patients’ progress
Nursing notes are used to track patients’ progress over time. It can help identify trends and patterns in a patient’s condition and can help assess the effectiveness of treatments.
2. Assess the effectiveness of treatments
Nursing notes can be used to assess the efficacy of treatments. It can help determine which treatments are working and which are not.
3. Communicate between healthcare team members
Nursing notes can be used to communicate between members of the healthcare team. It can help ensure that everyone is on the same page and can help avoid misunderstandings.
4. Serve as legal documentation
Nursing notes can serve as legal documentation in the event of a lawsuit. It can help ensure that the nurse’s actions are defended in court.
5. Educate other healthcare team members
Nursing notes can be used to educate other members of the healthcare team. It can help ensure that everyone is up to date on the latest developments in the patient’s care.
6. Assist in discharge planning
Nursing notes can be used to assist in discharge planning. It can help ensure that the patient is discharged to the appropriate level of care.
7. Help identify potential problems
Nursing notes can help identify potential issues. It can help the nurse take steps to prevent the problem from occurring or mitigate its effects.
8. Provide evidence-based practice guidelines
Nursing notes can provide evidence-based practice guidelines. It can help ensure that the nurse provides the best possible care to the patient.
9. Facilitate research
Nursing notes can facilitate research. It can help ensure that the latest evidence is being used to inform patient care.
10. Improve the quality of care
Nursing notes can improve the quality of care. It can help ensure that the patient receives the best possible care.
10 Tips for Writing Effective Nursing Notes
1. Write legibly
Illegible nursing notes can lead to miscommunication and errors in care.
2. Be concise
Long, drawn-out nursing notes can be difficult to read and understand. Stick to the facts and include only relevant information.
3. Use objective language
Avoid using opinionated or biased language in nursing notes.
4. Use standard abbreviations
Using standard abbreviations can help to ensure that your notes are legible and easy to understand.
5. Date and time of each note
It will help to ensure that the correct note is being referenced and will help keep track of the patient’s progress.
6. Include the patient’s name and the medical record number
It will help to identify the correct patient when referencing notes.
7. Use the nurse’s initials-
It will help to identify which nurses wrote the note. It will also help to ensure that the correct nurse is held accountable for the information included.
8. Re-read and edit notes before signing-
Double-check for any errors or omissions before signing off on a nursing note.
9. Keep notes confidential-
As a nurse, it’s your responsibility to keep the notes confidential to protect the patient’s privacy.
10. Follow the facility’s guidelines-
Each facility will have its guidelines for writing nursing notes. Follow these guidelines to ensure that all relevant information is included.
11. Focus on the patient, not the diagnosis
The focus of nursing notes should be on the patient and their response to treatment, not on the diagnosis or prognosis.
How to Store and Retrieve Nursing Notes?
Nursing notes can be stored electronically or on paper charts. If they are stored electronically, they should be password protected and backed up regularly. If they are stored in paper charts, they should be kept in a locked file cabinet.
How do I start writing nursing notes?
The best way to start writing nursing notes is to use a template. It will help ensure that all relevant information is included in each note.
How long should nursing notes be?
Nursing notes should be concise and to the point. They should include all relevant information without being so long that they are difficult to read or understand.
How often should I write nursing notes?
Nursing notes should be written at least once per shift. They may need to be written more frequently if the patient’s condition is complex or if significant changes in the patient’s condition.
Nursing notes are a vital part of the nursing process. They help document the care provided and the patient’s response to treatment. It can also be used to communicate between members of the healthcare team and to assess the effectiveness of treatments. When writing nursing notes, it is important to be legible, specific, and objective. Save notes in an appropriate manner. I hope this nurse notes example provided in this post will help you to understand the pattern of nursing notes.
Mrs. Marie Brown has been a registered nurse for over 25 years. She began her nursing career at a Level I Trauma Center in downtown Chicago, Illinois. There she worked in the Emergency Department and on the Surgical Intensive Care Unit. After several years, she moved to the Midwest and continued her nursing career in a critical care setting. For the last 10 years of her nursing career, Mrs. Brown worked as a flight nurse with an air ambulance service. During this time, she cared for patients throughout the United States.