5-Minute Summary: How to Take Great Nurses’ Notes
Learn the dos and don’ts of taking great notes on your patients.
Image via Unsplash.com/Trent Erwin
Nurses learn early and often that patient care is the No. 1 priority—but charting is a close second. Balancing charting and meeting your patient’s needs can be tough but is a necessity to accurately relay all updates to various providers. In fact, according to Science Direct, interdisciplinary communication is required for high-quality care, and improving communication will ultimately help improve patient outcomes.
Think about it this way: A nurse, doctor, or any other healthcare professional coming on shift is only as good as the charting they have on the patient. Nurses’ notes are an integral part of this chart, so they should be accurate, up to date, and concise. But how much detail is too much detail? And how can you balance patient interaction with taking accurate notes? You’re going to do a lot of charting and notating in your nursing career. These tips—and the accompanying nurses’ notes template—will help you make these assessments thorough, helpful, and less stressful.
What Are Nurses’ Notes?
Since nurses are 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.”
When nurses talk about charting, they are usually talking about the computer chart. Because many hospitals and clinics are going paperless, the physical (clipboard) chart may only have the patient’s history in it, while the computer chart has everything that happened during this stay.
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. American Nurse Today says making brief notes while assessing the patient will help you chart faster and give more accurate (formal) nurses’ notes right after your visit. This helps you move efficiently between each patient you need to see. Visit, chart, repeat.
What Should Nurses Include 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:
- Patient’s name
- Nurse’s name
- Reason for visit
- Vital signs
- Assessment of patient
- Labs and diagnostics ordered
- Evaluation of how medical interventions worked
- Family interactions
- Recommendations and observations
- Anything out of the ordinary
What Should Not Be Included in a Nurse’s Notes?
Lippincott Nursing Center states you should only include the facts, rather than your personal opinion. However, your opinion can be verbalized to other healthcare professionals so they can get a better picture of the patient (i.e., Social Services notified; request for one more day of stay due to patient unable to care for self at home).
Here are some other notations that cross an ethical line when put in formal/permanent notes:
- Personal information regarding family members and friends: While it’s OK to give very generalized information on them (i.e., they visited), nothing personal should be included (i.e., they were intoxicated, unkempt, uncaring, etc.).
- Dialogue you’ve had about patient between providers: Instead of conversation details, just note that you’ve informed certain physicians.
- Anything from the ISMP List of Abbreviations: These are often misinterpreted and lead to medication errors.
- Opinion: Instead, report on your recommendations and the systems you have put in place or staff you’ve notified. (i.e., This RN recommends social worker evaluate patient’s ability to obtain supplies needed at home upon discharge.)
- Negativity about staff that could be portrayed as defamatory: There should be another system for reporting staff issues within your organization.
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.
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:
- Chart concisely: Instead of a long-winded note, just add pertinent facts and keep it short.
- Be factual: Chart what you see, hear, and do.
- Read other nurses’ notes: Everyone will have their own voice. But you’ll see how veteran nurses balance their facts with their insight.
- Find a mentor: Look for an experienced nurse who you trust to give you constructive feedback on your notes.
- 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
- Chart after each visit: Take five minutes to chart and write thorough nurses’ notes right away, this way it is fresh in your mind.
- 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.
- Note responses: Express how the patient responded to treatment. Chart whether they adhered to advice given by you and the doctor.
- Describe observations: Write down all pertinent observations with the patient. For example, “color pink, swelling to lower extremities, pain 4⁄10.”
- Never speculate: We always want to write how we feel the patient feels, but this is not usually accurate. Instead, chart what the patient is literally saying.
- Use your resources: Know that you have resources around you. Use the nurses who have been around for a long time. Their experience is valuable. 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.
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