Taking nurses notes is a regular practice in patient care. But putting together nursing notes can be a little tricky – you want to be able to capture all the information you need in as few words as possible, but you also don’t want to leave out any important details.
Writing nursing notes is one of the core responsibilities of being a nurse, and learning how to write them effectively and quickly will set you up for success in your future career.
The most effective nursing notes include terminology, observance, detail, and readability. Whether you’re in clinicals or on the job, it’s important to understand why and how they’re crucial to providing quality care.
We’ll show you what goes into nursing notes and how to write them effectively for the best patient care.
But first, let’s get into how they’re relevant to charting.
Nursing Notes vs. Charting
Nursing students learn charting (along with notes) early and often to better paint a picture of the patient’s health at the time of the visit or for the duration of the time. Charting includes the notes made by nurses and put into a computer.
Charting information is purely objective (IV site documentation, alarms, test results, etc.), and are set up specifically for each working medical facility.
Making quick notes when evaluating the patient will enable you to chart more quickly and provide more accurate nurses’ notes immediately.
Read here to learn how notes and charts fit into the nursing process.
How Are Nursing Notes Used?
The first thing to know about nursing notes is that they’re not just for patients but also for nurses. Nurses notes fill documentation gaps between doctors, patients, and other providers.
The primary purpose of a nursing note is to track the progress of the patient’s condition over time.
You also may share notes with other team members, depending on their role within the department. This allows them to adjust treatments accordingly if necessary (e.g., increasing dosage).
What Do You Write in Nursing Notes?
In short, you write everything you observe as a nurse and any significant medical information. Nursing notes include information about how the patient feels, what they need, and what’s going on with their health in a short, detailed summary.
When you put every piece of information together, make sure that everyone who needs to know about a patient’s care can access that information quickly and easily.
What’s Included in a Nurses Note?
The information included in a nurses note varies depending on the facility’s needs and the type of care being provided. Nurses notes are often filled with abbreviations and medical jargon – which you and staff will know, but the patient most likely won’t.
Generally, here’s what you can expect from your nurse’s notes:
- General patient information: name, gender, age, address.
- Reason for their visit & Chief complaint: What they came in for and how long they’ve been under your care.
- Observations: What you’ve observed during your time with them (what they look like when they’re awake or asleep, their breathing patterns and heart rate, etc.).
- Treatment plan: A care plan layout based on the collection, analysis, and organization of nurses’ clinical data.
- History: Patient history including present and past ailments.
- Medication(s): Any medications given to the patient (including dosage details), along with medication history.
- Ending summary: An overall evaluation of their condition at the time of discharge.
Ideally, you should take brief notes while you’re in the same room as the patient, and add more detail as soon as you leave the patient’s room while the information is still current and fresh in your mind.
Good Nursing Notes Examples
The following are four nursing notes examples varying between times of a patient’s admittance:
Acute Pancreatitis Nursing Notes
Patient Name and Age: Kane Schneider, 33
Date: May 14th, 2022
Chief Complaint: The patient’s chief complaint is acute pancreatitis, which they developed after eating a large amount of greasy food. The patient also reports that they have been experiencing nausea and vomiting since they arrived at the hospital.
Diagnosis: Acute Pancreatitis
History: The patient reports that they have had similar symptoms in the past and have had several episodes of acute pancreatitis over the past few years. The patient has had all of their gallbladders removed in attempts to treat this condition.
The patient has not been taking any medication for nausea, but has been receiving IV fluids for hydration due to their vomiting.
Physical exam: Vital signs are stable — pulse = 72 beats per minute, respirations = 16 breaths per minute, temperature = 98.2 degrees Fahrenheit (F). Physical examination reveals a pale and diaphoretic person in moderate distress with abdominal tenderness on palpation in the epigastric area.
No jaundice or bruising is present on examination of the skin or mucous membranes. Abdominal distention is present with peripheral edema noted around the umbilicus area as well.
Urinary Tract Infection Nursing Notes
Patient Name and Age: Elaina Hassan, 77
Date: January 29th, 2022
Chief Complaint: She has been experiencing fever, chills, and dysuria for two days.
History of Present Illness:
Patient has previously experienced mild hypertension and heart failure.
Physical exam: Vitals – The patient’s temperature is 99 degrees Fahrenheit. The pulse is 100 beats per minute and regular. The blood pressure is 140/90 mm Hg.
Diagnosis: Urinary tract infection.
Assessment: She appears to be in moderate distress and is slightly tachycardic at 104 beats per minute. Patient demonstrates evidence of right lower quadrant tenderness on palpation as well as suprapubic tenderness on deep palpation. The patient’s urine dipstick test reveals 1+ blood and no white blood cells or nitrites present in her urine sample.
Evaluation: She has been treated with antibiotics and fluids, and can now urinate without discomfort.
Alcohol Withdrawal Nursing Notes
Patient Name and Age: Willie Brandt, 41
Date: March 21st, 2022
Diagnosis: Alcohol withdrawal
Assessment: Patient was brought in by his family for alcohol withdrawal. When they brought him in, he was experiencing tremors, hallucinations, and confusion.
History: Patient has been drinking alcohol for 24 years, and his family noticed that he started to drink more heavily over the past few years.
Plan of care: Monitor vital signs every 15 minutes; check urine output every hour; administer IV fluids as ordered; administer medication as ordered (e.g., benzodiazepines); monitor electrolytes every 6 hours or as ordered; provide emotional support to patient and family; educate patient on how to avoid future episodes.
Upper Respiratory Infection Nursing Notes
Patient name and Age: Jazmin Adkins, 25
Diagnosis: Upper respiratory infection, including rhinitis and pharyngitis.
Assessment: Patient presented with symptoms of a cold, including runny nose, sore throat, cough, and congestion. Symptoms have persisted for 2 weeks.
History: Patient works as a bartender at a local restaurant. Two evenings per week she works late into the night and does not get enough sleep; she also drinks alcohol on these nights (about 4 drinks).
She washes her hands frequently at work but does not use hand sanitizer before touching his face or putting his hands in his mouth. Patient often smokes cigarettes outside work hours and is always around cigarette smoke when out with friends or family members who smoke regularly.
General Tips for Writing Nursing Notes
Sometimes it can be hard to know where to start, or how to make your notes stand out from the rest of your peers.
When writing a nurse note, you must first think about what is important for the patient. But it’s also important to ask yourself: what’s important for the rest of your team?
Here are some simple tips for writing the perfect nursing note:
- Stay on point and be specific.
- Use shorter sentences when possible for easier reading.
- Include interdisciplinary team members.
- Use bullet points when possible (it’s much easier to scan through a list than long paragraphs).
- Sign each entry of your note with your name and credentials.
- Use correct grammar and spelling (and avoid autocorrect).
- Add new information throughout the patient’s visit.
- List a patient’s most important condition and its severity level (for patients with multiple conditions).
- Don’t forget the little details.
- Include patients’ room and bed numbers at the top of the page (if you’re writing a note for an inpatient).
Take Your Nursing Learning to the Next Level
Taking nurses notes will be one of many, many job responsibilities you’ll have. You’ll be better prepared for success in your future work if you can write them efficiently, promptly, and with the maximum amount of detail.
You’ll have great nursing notes when you can quickly balance medical terminology, writing skills, detail, and observation.
To get all of that down easier and more efficiently, you’ll need a supplemental resource. SimpleNursing offers just about everything you need (study guides, question banks, assessments, and more) to perfect your nursing process.
Get the most out of your nursing courses and effectively put them together in your studies.
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