NURSES NOTE
Definition
A nurse’s note is any written or electronically generated information about a client that describes
the care or service provided to that client. Through nurses’ notes, nurses communicate their
observations, decisions, actions and outcomes of these actions for clients. The nurse’s note is an
accurate account of what occurred and when it occurred.
The nurse’s note clearly describes:
• An assessment of the client’s health status, nursing interventions carried out, and the impact
of these interventions on client outcomes;
• A care plan or health plan reflecting the needs and goals of the client;
• Needed changes to the care plan;
• Information reported to a physician or other health care provider and, when appropriate, that
provider’s response; and
• Advocacy is undertaken by the nurse on behalf of the client.
Purposes of nurse’s note
• To facilitate communication
• To promote good nursing care
• To meet professional and legal standards
METHODS OF NURSE’S NOTE
FOCUS CHARTING
With this method of documentation, the nurse identifies a “focus” based on client concerns or
behaviours determined during the assessment.
In focus charting, the assessment of client status, the interventions carried out and the impact of
the intervention on client outcomes are organized under the headings of data, action and
response.
Data: Subjective and/or objective information that supports the stated focus or describes the
client’s status at the time of a significant event or intervention.
Action: Completed or planned nursing interventions based on the nurse’s assessment of the
client’s status.
Response: Description of the impact of the interventions on client outcomes.
SOAP / SOAPIER CHARTING
SOAP/SOAPIER charting is a problem-oriented approach to documentation whereby the nurse
identifies and lists client problems; documentation then follows according to the identified
problems.
Nurse’s note is generally organized according to the following headings: S = subjective data
(e.g., how does the client feel?)
O = objective data (e.g., results of the physical exam, relevant vital signs)
A = assessment (e.g., what is the client’s status?)
P = plan (e.g., does the plan stay the same? is a change needed?) I = intervention (e.g., what
occurred? what did the nurse do?)
E = evaluation (e.g., what is the client outcome following the intervention?) R = revision (e.g.,
what changes are needed to the care plan?)
NARRATIVE CHARTING
Narrative charting is a method in which nursing interventions and the impact of these
interventions on client outcomes are recorded in chronological order covering a specific time
frame. Data is recorded in the progress notes, often without an organizing framework. Narrative
charting may stand alone or it may be complemented by other tools, such as flow sheets and
checklists.
Nursing Notes vs. Charting
Charting is a nursing process that includes all the documentation required from nurses. This might
include legal, professional, and institution-specific requirements. Some examples of charting
include documenting medications administered, vital signs, physical assessments, and
interventions provided. Nursing notes are a narrative written summary of a given nursing care
encounter. This might include a description of a nursing visit, a specific care event, or a summary
of care. A nurse’s note is a form of charting that describes the nurse’s decision-making process
regarding the nursing care provided.
Nursing notes are an important part of high-quality nursing documentation because they provide
an opportunity for nurses to demonstrate their nursing knowledge and communicate the nursing
process to other team members of the patient’s interprofessional care team.
The following are some tips to keep in mind when charting Nurse’s note
Follow these rules for charting
• chart everything:
• include observations,
• nursing actions,
• patient’s response to therapy and treatment,
• any unusual incidents or omitted treatments
• safety precautions you took to protect the patient
• your attempts to reach the doctor
• any reservations you have about a doctor’s orders
• the date and time of each entry
• the patient’s name and identification number off the chart
• your signature on each entry (when in doubt chart everything)
• leaving blanks or omitting documentation could have disastrous results in a lawsuit
• Be specific: avoid being general or vague.
• Do not obliterate an entry. The obliteration of any entry will only provide more
ammunition for the plaintiff attorney. In some instances, this may be considered fraud and
will subject the institution and you to civil and criminal penalties.
• Chart as you go. This is easier said than done.
• If you observe changes in the patient, do not just chart them, but also notify the
physician. If the physician becomes abusive or does not respond appropriately, notify the
proper administrative personnel to assist in resolving the matter.
• If you make a mistake in charting-correct it after the last entry you made-not where you
should have made it in the first place.
• If you are asked to chart for someone else don’t do it. But if you are unable to refuse,
include the name of the person you are charting for. Then sign your name. The signing of
any document for anyone is strongly frowned on.
• Above all, do not try to cover up a mistake. Be candid with both family, physician and
your institution.
General Information
1. Documentation is the foundation of good nursing practice
2. There are multiple types of charting methods utilized
3. All methods are based on the nursing process
• Assessment: observation for signs of actual or potential problems
• Planning: determining a plan of care targeting identified issues
• Implementation: the actions required for the resolution of the problem
• Evaluation: reviewing the plan of care for effectiveness
4. Several principles apply to all charting methods
• "If it isn't charted, it's not done"
• Timeliness is important: chart as care is provided, and do not wait until the end of
the shift to record the day’s work
• Charts are legal documents and should be accurate, concise, and complete
• Never chart prior to actually performing care (ie don't chart medications given
until the patient actually takes them)
• Use straightforward language: provide accurate measures ("ate 90% of dinner"
not "ate well")
• Provide objective information; avoid subjective observations and assumptions
• Avoid the use of personal comments or judgements
• Refer to each institution's policies and procedures for specific information
5. JCAHO has established a list of non-allowed medical abbreviations which will be included in
an institution's policies.
• Write "unit", not "U"
• Write "international unit", not "IU"
• Use "daily", not QD
• Use "every other day", not QOD
• Never write a zero after a decimal point
• Always write a zero before a decimal point
• Write "Morphine Sulfate", not MS
• Write" Magnesium Sulfate", not MSO4
❖ Narrative Charting
• Written notes in chronological order
• Usually, a sentence structure
• May be time-consuming with significant amounts of writing
❖ SOAP
• Acronym for Subjective, Objective, Assessment, Plan
• May also include Implementation and Evaluation (SOAPIE)
• Related documentation follows each letter
❖ PIE
• Acronym for Problem, Intervention, Evaluation
• Condensed subjective and objective information
• Similar method for APIE: Assessment, Plan, Implementation, Evaluation
❖ Flow Sheets
• May also be referred to as "Graphics"
• Used for quick reference
• Often record intake/output, vital signs, medications, or weights
• Time parameters may vary from every five minutes, to once a shift or every 24hr
• Use caution to not just repeat what was checked previously
• Documentation required with patient status change
• Easy to mark wrong boxes or miss places requiring documentation
❖ Charting by Exception
• Only unexpected or significant findings are documented
• Normal findings are not recorded.
• With deviations, more complete nurses’ notes are completed to describe the situation and
interventions.
• Usually utilizes flow sheets or charts.
• Very efficient, but has potential for incomplete documentation.
NURSES RECORD FORMAT
Bibliography
➢ [Link]
➢ Jean Barrett “Ward management and teaching” Konark Publishers PVT LTD [Link]: 182-
195.
➢ Lally, S. (1999). An investigation into the functions of nurses’ communication at the inter-
shift handover. Journal of Nursing Management, 7, 29-36.