Writing the Nurse Note

Hi,
we have learned many things related to Nurses’ Equipments as you can see in the following link.

Now, we will try to write the Nurses’ Note.

What Are Nurses’ Notes?
Nurses can become patient advocates and often have the most contact with their patients. Their notes provide the most complete picture of the patient’s health to the other health professionals and specialists involved in their care. These notes are the formal documentation that nurses make when charting, based on the notations and scribbles nurses gather during a patient visit. They may also incorporate charting by exception, a shorthand way of noting the “exceptions” or abnormalities the patient is experiencing by initialing lists and charts.

Keeping thorough and accurate notes is extremely important for maintaining effective communication between nurses and the medical staff, but if a malpractice case is ever filed, these charts will be used by the legal team involved. Considering that nurses care for a number of patients at a time, the formal notes taken on a patient will help a nurse remember the events of the day, the care provided, and the specialists involved if she’s ever sued or called as a witness.
What Are Some Examples of Nurses’ Notes?
Here are some examples of good nurses’ notes to give you a little more context:

“When I walked in the room, the patient was blue and having trouble breathing. I called a Code Blue and started CPR. Then Code team arrived.”

“Lung sounds clear to auscultation bilaterally. Color pink. No signs of respiratory distress noted. VSS. Patient eating 90% of his meals and tolerating well. No abdominal distention or emesis this shift. Patient ambulating adequately. Voiding spontaneously. No BM this shift. Patient’s weight remained the same. Spouse visited patient today. Bed rails up x4. No hazards in room. Call light within reach.”

What’s the Difference Between Nurses’ Notes and Charting?
Nurses’ notes are part of charting. They are short-form notations on pre-established lists (charting by exception), often with a one-paragraph summary that gives a picture of the patient’s health during the visit or time period.

When Should Nurses Chart Their Notes?
Ideally, you make quick notations during your visit and add more depth immediately after you leave the patient’s room, when the information is fresh and top-of-mind.

What Should Be Included in Nurses’ Notes?
The three thoughts to keep in mind when you’re writing these notes are:

Will this help all other staff members working with this patient?
Did this summarize the patient’s current experience?
Would this help remind me of the patient’s condition and care five years from now if I ever need to testify on this case?
Because your notes are so important, Tricia Chavez, RN, educator from Redlands Community Hospital in Redlands, California, suggests you include:

Date/time
Patient’s name
Nurse’s name
Reason for visit
Appearance
Vital signs
Assessment of patient
Labs and diagnostics ordered
Evaluation of how medical interventions worked
Instructions/education
Family interactions
Recommendations and observations
Anything out of the ordinary

Here are some other notations that cross an ethical line when put in formal/permanent notes:

1) Personal Information Regarding the Patients’ Family Members & Friends
While it’s OK to give very generalized information on them (e.g., they visited), nothing personal should be included (e.g., they were intoxicated, unkempt, uncaring, etc.).

2) Dialogues You’ve Had About Patients Between Providers
Instead of conversation details, just note that you’ve informed certain physicians.

3) Anything From the ISMP List of Abbreviations
These are often misinterpreted and lead to medication errors.

4) Your Opinion
Instead, report on your recommendations and the systems you have put in place or staff you’ve notified (e.g., this RN recommends social worker evaluate patient’s ability to obtain supplies needed at home upon discharge).

5) Negativity About Staff That Could Be Portrayed as Defamatory
There should be another system for reporting staff issues within your organization. But there are ways around saying what you want to say. For example:

You want to say: “The doctor isn’t concerned about something that I’m concerned about.”

But actually say: “MD notified. No further orders.”

You want to say: “I’m concerned the patient’s grandmother is abusive to patient.”

But actually say: “Please evaluate grandmother for care after discharge” in Social Services order. Then, speak freely when Social Services talks to you in person.

As an aside, you should never chart after your shift. If, for whatever reason, off-duty charting is needed and/or necessary, you should comply with your employer’s instructions or seek guidance from your supervisor on how to handle the situation.

11 Tips for Writing Excellent Nurses’ Notes — From a Nurse
As a nurse since 2001 and mentor at my hospital, here is the advice I give to new nurses:

Tip #1: Be concise.
Instead of a long-winded note, just add pertinent facts and keep it short.

Tip #2: State the facts.
Chart what you see, hear, and do.

Tip #3: Read other nurses’ notes.
Everyone will have their own voice. But you’ll see how veteran nurses balance their facts with their insight.

Tip #4: Find a mentor.
Look for an experienced nurse who you trust to give you constructive feedback on your notes.

Tip #5: Write shorthand.
Keep shorthand notes while talking. Keep eye contact while writing shorthand keywords for your post-visit write-up. Then chart it as soon as you can after. For example, if your patient is describing sharp stomach pains, you might write “9/10 pain/LLQ.”

Tip #6: Chart after each visit.
Take five minutes to chart and write thorough nurses’ notes right away; that way, it’s fresh in your mind.

Tip #7: Summarize.
In the hospital setting, write an end-of-the-day note in each patient’s’ chart, starting in the morning and go through the entire day. A good summary is helpful to everyone involved with the patient. In the clinic setting, there should be a summary in each patient’s’ chart with every visit.

Tip #8: Note responses.
Express how the patient responded to treatment. Chart whether they adhered to advice given by you and the doctor.

Tip #9: Describe observations.
Write down all pertinent observations with the patient. For example, “color pink, swelling to lower extremities, pain 4/10.”

Tip #10: Never speculate.
We always want to write how we feel the patient feels, but this isn’t usually accurate. Instead, chart what the patient is literally saying.

Tip #11: Use your resources.
Know that you have resources around you. Use the nurses who have been around for a long time; their experience is invaluable. There are usually charge nurses or nurse managers you can utilize. It’s always better to ask for help than to not chart enough information.

source:https://www.berxi.com/

4 thoughts on “Writing the Nurse Note”

  1. Fatimah Nurmala Sari

    Name : Fatimah Nurmala Sari
    Nim : 191000214201010
    Prodi : S.1 Ilmu Keperawatan
    Semester 2
    B.English : (assignment about nurse records)

    Identity
    Name : Nurhayati
    Gender : Women
    Age : 50 th
    Religion : Islam
    Tribes/nation : Payakumbuh/Indonesia
    Education : SLTA
    Profession : Housewife
    Address : Sicincin
    On June 22,2019,at 11:30 WIB the Nurhayati’s mother came to the emergency room with diarrhea complaints for 2 days.Frequency of slimy bowel movements 4-5 times every day.According to nurses’ observations,the client’s body is hot,the color and smell of a stool is typical.After being asked again the client said before eating spicy food.
    Based on physical examination obtained vital sign:
    Tension : 110/70 mmHg
    Pulse : 78X/ menit
    Temperature : 37,5 c
    General state : Weak,pale lips
    After being given medical treatment the pasien is allowed to go home.

    Nurse’s signature and name

  2. Name : Yunita zahra
    Nim : 191000214201009
    Prodi : ilmu keperawatan
    “Nursing note”
    Mr. A in bed number four, 32 years old was a client of Dr. Lang’s, scheduled for a colonic resection this morning. She had been suffering from ulcerative colitis for 2 years. She was received last night with abdominal pain complaints. This was his first surgical experience. He knew that he would likely have to use colostomy.
    1. Examination : Mr. A expressed difficulty in sleeping last night. He asked several questions about surgery. At night she called the nurse for help several times.
    2. Nurse diagnosis: the main problem with nursing is the lack of knowledge relating to inexperienced surgery and the ansietas of potential change in body image.
    3. Action: the cleaning enema has been made clear at 9:00 p.m.; No blood found on liquid enema. She suffered abdominal cramps soon after the enema, but then she disappeared. He gets 15 mg Po at 23:30 and I do a back massage for him. He fell asleep after midnight.

  3. GERONTIC NURSING CARE IN Tn “R” USING CARDIOVASCULAR SYSTEM DISORDERS IN HYPERTENSION CASE
    IN VILLAGE BAREJULAT KEC. CENTRAL LOMBOK TONGUE

    Day / date: Saturday, December 19, 2015
    Place: Barejulat Village, Jonggat District, Central Lombok
    I. ASSESSMENT
    1. IDENTITY
    Client Identity
    Name: Mr. “A”
    Age: 56 years
    Male gender
    Address: Barejulat Village, Jonggat District, Central Lombok
    Status: Married
    Islam
    Sasak tribe
    Education: high school
    Occupation: retired
    Person in Charge Identity
    Name: Mrs. “I”
    Age: 49 years old
    Address: Barejulat Village, Jonggat District, Central Lombok
    Relationship with clients: Wife
    2. HEALTH HISTORY
    2.1 Main Complaints: Dizziness
    2.2 Current Disease History
    When conducting a study the client came to the posyandu with a headache complaint since 3 days ago, the client said the pain was throbbing and stiff neck, pain came at any time, the client seemed to hold his head, before the client had been treated by a shaman but there was no change , the client also said joint pain and blurred vision, the client wondered about the disease, and at this time the disease felt by the client is hypertension.
    2.3 Past Disease History
    The client also experienced dizziness, joint pain and itching in the past 3 months,
    3. PHYSIOLOGICAL STATUS
    3.1 Spinal posture: the client’s spinal posture when walking upright.
    3.2 The client’s vital signs
    TD: 160/90 mmHg
    N: 87 x / minute
    S: 36.7 oC
    RR: 20 x / minute
    BB: 45 kg

  4. GERONTIC NURSING CARE IN Tn “R” USING CARDIOVASCULAR SYSTEM DISORDERS IN HYPERTENSION CASE
    IN VILLAGE BAREJULAT KEC. CENTRAL LOMBOK TONGUE

    Day / date: Saturday, December 19, 2015
    Place: Barejulat Village, Jonggat District, Central Lombok
    I. ASSESSMENT
    1. IDENTITY
    Client Identity
    Name: Mr. “A”
    Age: 56 years
    Male gender
    Address: Barejulat Village, Jonggat District, Central Lombok
    Status: Married
    Islam
    Sasak tribe
    Education: high school
    Occupation: retired
    Person in Charge Identity
    Name: Mrs. “I”
    Age: 49 years old
    Address: Barejulat Village, Jonggat District, Central Lombok
    Relationship with clients: Wife
    2. HEALTH HISTORY
    2.1 Main Complaints: Dizziness
    2.2 Current Disease History
    When conducting a study the client came to the posyandu with a headache complaint since 3 days ago, the client said the pain was throbbing and stiff neck, pain came at any time, the client seemed to hold his head, before the client had been treated by a shaman but there was no change , the client also said joint pain and blurred vision, the client wondered about the disease, and at this time the disease felt by the client is hypertension.
    2.3 Past Disease History
    The client also experienced dizziness, joint pain and itching in the past 3 months,
    3. PHYSIOLOGICAL STATUS
    3.1 Spinal posture: the client’s spinal posture when walking upright.
    3.2 The client’s vital signs
    TD: 160/90 mmHg
    N: 87 x / minute
    S: 36.7 oC
    RR: 20 x / minute
    BB: 45 kg

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