What Are Nursing Notes?
A nursing note is an official health record used to document precise details about every nursing assessment, service provided, change in the patient’s condition, patient admission, and other medical or clinical-driven data. It works similar to a doctor’s note except that nursing notes are written by nurses already. And covering nursing notes has been practiced among hospitals and medical facilities worldwide.
According to Nursing Practice Insurance, Liability Insurance Nurses (NSO), documentation defends nurses in malpractice lawsuits, hence, keeping them out of court.
Important Records in a Nursing Note
Yes, it is clear that nurses write essential information about their patients and what services were provided under nursing notes. But what exactly can be found inside such notes? In this section, identify the common important records found in nursing notes.
Patient’s Appearance: Nurses describe how the patient looks like or how he or she is doing. The thing is, they can tell from appearance if someone is healthy or not. And this part covers brief descriptions and actual checkups alone instead of relying too much on opinions.Current Condition of Patients: As a patient gets hospitalized, nurses track their condition regularly. Tracking regularly helps nurses trace the patient’s medical history until their most recent condition.Charting: There is a series of charts in a nurse’s note to document medical records and services from diagnostic test results, patient interactions, services performed, and more. And that process is known as charting.Nurse Assessment: Most importantly, a nurse’s assessment report comes in handy. This section summarizes the nurse’s evaluations while at work in the most detailed but precise way possible.Progress Notes: Another significant element is the progress notes. There is likely a narrative sequence in the notes from what happened first until the last part. And the progress checks if things improved or the other way around. Also, what is documented helps protect nurses against any malpractice lawsuit.
How to Make Nursing Notes
Using the sample nursing notes listed above, you won’t need to start from the very beginning in creating nursing notes. Just use the sample to edit your content, download it anytime, and print as many times as you want. Easy-to-use and customizable templates make it worth your time for sure. And to ensure you cover everything right, follow these important steps as well:
Step 1: Know Your Tasks and What to Cover
As a nurse, what would be your duties? And what should you cover under your notes? Finalize your roles and tasks to be sure of what to input in the notes. Instructions may differ from one hospital to another. But the common denominator is that you will really cover those important records in a nursing note, which were already discussed earlier. Your purpose will promise you to be guided on what to write along the way.
Step 2: Insert Relevant Labels and Categories into a Template
Labeling and categorizing notes is part of the process, especially when charting is one of the main concerns there. So using a sample template, slowly insert the needed labels and groups for the nursing note. You could tackle head-to-toe examination, wound checkups, late entry records, patient information, health assessment, deceased or not, and so much more.
Step 3: Write Neatly and Specifically
How you write also affects the results. The key is to be very specific with your words and write neatly in the document. That means you avoid abbreviations that may mean different things from other perspectives. And you organize your data promptly so you won’t get confused in following the whole note’s content. Rest assured, your writing slowly improves as you practice note-taking from time to time.
Step 4: Be Timely in Note-Taking
Monitoring a patient’s health requires regular note-taking. So be sure to supervise timely and record essential findings every hour, if you can. Otherwise, your evaluation might fail if there were important points that have not been recorded due to how your details are already outdated. And most importantly, keep extra copies of your notes in case they get lost. Thus, you are still covered with the data from the extra notes.
What are the top three important questions to answer in nursing notes?
For your nursing note, be sure to answer the following set of questions:
- Will this data help the rest of the staff who worked with the patient?
- Did the data sum up the patient’s experience?
- Would this data remind me of the patient’s health condition and service about how many years from now, in case you testify on this particular case?
What are some common labels to write under nursing notes?
In writing nursing notes, you are expected to write about the date, patient’s name, nurse’s name, the purpose of visit, appearance, vital signs, patient assessment, diagnostics or lab tests, evaluation of medical interventions, family interactions, additional instructions, and other observations.
What should you not include in nursing notes?
Although nursing notes need to be detailed, there is no need to include the patient’s family members’ or friends’ personal details, random abbreviations, dialogues between the provider and the patient, negativity about the staff, and personal opinions.
In conclusion, nursing notes play a very crucial role among nurses in a hospital or medical facility. Without all the data covered there, it may be hard to answer significant questions and prove what is right or wrong in court. So start note-taking using sample nursing notes now!