Essential Nursing Notes for Patient Care
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ScribdTranslationsEssential Nursing Notes for Patient Care
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ScribdTranslationsFACULTY OF HEALTH SCIENCES
PROFESSIONAL SCHOOL OF NURSING
Monograph Title:
Nursing Notes
AUTHORS:
- Velasquez Tufinio Gloria Magdalena (0000-0003-4941-6288)
- Zavaleta Huamán Yomara Carolina (0000-0003-3853-0261)
ADVISER:
Lic: Neuza Marilia de la Trinidad Huertas Salvatierra (0000-0003-0983-4696)
LINE OF RESEARCH:
Policies and management in Health
TRUJILLO – PERU
2021-II
INDEX
I. INTRODUCTION.......................................................................................................................3
BACKGROUND:........................................................................................................................3
GOALS:.......................................................................................................................................4
General objective:................................................................................................................4
Specific objectives:..............................................................................................................4
JUSTIFICATION :......................................................................................................................5
Professional:.........................................................................................................................5
Academic :.............................................................................................................................5
II. BODY..........................................................................................................................................6
NURSING NOTES..........................................................................................................................6
III. CONCLUSIONS........................................................................................................................8
BIBLIOGRAPHIC REFERENCES...............................................................................................9
ANNEXES:....................................................................................................................................11
I. INTRODUCTION
The 2nd cycle students of the nursing school at the Caesar Vallejo University will
carry out the following monograph nursing notes. We chose this topic due to the
great importance that this document contains that it will provide to the patient in
their care, this information content reflects the actions that the nursing staff, who
perform to improve the patient's health status, and achieve a prompt reintegration
into society, family and community. It is also considered that this dispute has
importance in legal proceedings.
Florence Nightingale notes: “That these notes are in no way intended to be a rule
of thought by which nurses can teach themselves to care, much less a manual for
teaching nurses the art of caring. 1
The World Health Organization (WHO) defines quality as the "High level of
professional excellence using resources efficiently with a minimum of risks for the
patient to achieve a high degree of satisfaction of the patient's needs and
producing an impact." positive ending in health" 2
Nowadays it is recorded that nursing staff have a deficiency in registration and
knowledge of the nursing note according to established standards. These records
are incomplete taking into account the writing criteria, poor spelling, lack of clarity,
even some unwritten notes, and this causes confusion regarding the patient's care
and recovery plan. 4
BACKGROUND:
There are studies related to research, such as the one carried out by Anglade. V
Nursing notes constitute one of these records since the planning, execution and
evaluation of the care provided by the nursing staff are reflected here; therefore,
these records show the skills of the nurse and the quality of care provided. is
provided at the institution .5
Likewise Quispe. Q The quality of care has a value as important as health; That is
why nursing staff, as a member of the health team, must develop a culture of
quality and provide care with a proactive attitude. 6
In the 19th century, Florence Nightingale was looking for something different for
nursing, valuing care and not just the fact that nursing means the administration of
medicines. She demonstrated with statistical data and defined nursing as putting
the patient in the best conditions for nature to act. She considers that nursing
needs to be prepared and intelligent and should be remunerated for the quality of
work. After a century, the importance to the nursing profession and to the nurse.
In these years, there is a search to increasingly professionalize nursing work.
In Peru, the Nursing Care Process is to provide comprehensive nursing care.
Comprehensive nursing care is understood to be provided to the person at all
stages of life, from conception to death, including health and disease, applying the
scientific method through the Nursing Care Process, guaranteeing the quality of
care, a nurse must be objective and truthful in their reports, statements, verbal or
written testimonies, related to their professional performance.
This is why the importance of nursing records, which are daily notes made by
nursing staff during their work day with the purpose of communicating the
technical and clinical aspects related to patient care or nursing care. Ensures
quality, continuity of care, improved communication and avoids errors. In addition,
they are legal support for possible lawsuits and also allow the quality of care
provided during the hospital stay to be retrospectively evaluated.
GOALS:
General objective:
Promote nursing notes that benefit the patient, family and nursing
professionals.
Specific objectives:
Publicize the results of how nursing notes are important in the patient's
prompt recovery of health.
Contribute to the comprehensive care of the patient in such a way that the
records constitute a valuable resource for the constant evolution before the
nursing process.
JUSTIFICATION :
Professional:
Due to the above, there is a need to contribute with the importance regarding
nursing notes.
Academic :
Prepare the analysis of nursing notes applying the knowledge acquired during
the subject of Methodology for patient care at the César Vallejo University.
II. BODY
NURSING NOTES
The nursing note is a concrete, clear, objective, understandable and systematic
written tool of the findings, activities, observations, decisions and care provided to
3
the person, family or community, immediately after their completion.
Dugas considers it as “The written record that is left of the essential facts in order
7
to have a continuous history of the events that occurred during a certain period.”
According to Technical Standard No. 029-MINSA on the Health Care Quality Audit
of the MINSA, it indicates that nursing notes are a basic instrument of the nurse,
as they will provide information on the patient's daily status throughout their
hospital stay, as well as of care and evolution. 8
Therefore, nursing notes are important for the care provided by nursing staff,
allowing a record called Kardex (Annex 1), which indicates delivery and receipt of
shift, medication prescription, vital signs. , hydroelectrolyte balance, neurological
evaluation of each day. The quality and written evidence of care, this testimonial
document before the judicial authority, is legal. Likewise, it provides such
9
information that is useful in undergraduate and graduate training and research.
The types of records will be: narrative, descriptive, consolidated, diagram and/or
flow, admission notes and discharge notes. 10
As a characteristic in the care record, it must reflect the problems, needs,
strengths and limitations evident in the patients, recording accurately, it should not
be altered, it must be written as the patient was found at the exact moment. It will
demonstrate in a logical, clear and complete manner the procedure that was
performed and the patient's health condition, as well as the treatment
administered, its possible adverse reactions and all the care provided during the
hospital stay. eleven
Therefore, Nursing notes, being a legal document that supports the entire health
service, should not have the presence of erasures, amendments or blank spaces
(an oblique line will be drawn in the blank spaces) and much less illegibility; The
information must be written in descriptive form. It begins with date and time, as
well as subjective data (expressed by the patient that will be noted in quotes),
objective data (based on staff observation), assessment, planning of activities,
execution, verification and evaluation of these. Descriptive; It begins with
subjective data (expressed by the patient), objective data (based on staff
observation), assessment, planning of activities, execution, verification and
evaluation of these. eleven
Colors can be used depending on the time of entry, black will be for 7:00am to
7:00pm and red will be from 7:00pm to 7:00am, this varies depending on the
10
health institution and/or country in which it is located. work
There is SOAPIE (systematic method of recording and interpreting patient health
problems); Its acronym corresponds to the following content: S: subjective, O:
objective, A: data analysis and interpretation, P: care plan, I: intervention, and E:
evaluation of expected results; It is completed by placing the seal and signature of
the nurse (Annex 2). 12
Quality of illness notes according to their content can be: physical evaluation,
interaction behavior, state of consciousness, physiological conditions, education,
information. 5
[Link]
Nursing notes are the detailed and orderly record of the physical, mental and
emotional state, evolution of the disease and the respective care of the
patient.
The acronym SOAPIE is used to write it taking care of the quality standards of
all medical records since this is a legal document.
It serves as both research, academic, and administrative at undergraduate
and graduate levels.
BIBLIOGRAPHIC REFERENCES
1. Naranjo Y, Álvarez R, Mirabal J, Álvarez B. Florence Nightingale, the first
nurse researcher. Arch Méd Camagüey. 2020;24(3):450-9
2. SalusPlay. Complete classification of NANDA-I nursing diagnoses 2015-
2017 [Internet]. [Link]. 2017 [cited April 30, 2021]. Available at:
[Link]
3. Fernández S, Ruydiaz K, Toro M. Nursing notes: a look at their quality.
Uninorte Health. Barranquilla (Col.) 2016; 32 (2): 337-345
4. Anglade C. Characteristics of nursing notations and personal and
institutional factors associated with their development at the Dos de Mayo
hospital [Bachelor's degree]. National University of San Marcos. 2006
5. Quispe E. Quality of nursing notes in the Intermediate Treatment Unit of the
National Institute of Neoplastic Diseases 2016 [Bachelor's degree]. National
University of San Marcos. 2016
6. InfoSalud Home. Maternal and child nursing notes [Internet]. [Link].
2013 [cited 2021 Jun 4]. Available at:
[Link]
7. Dugas, Berbely (2000). Practical Nursing Treatise. 4th. McGraw – Hill
Edition – Inter-American. Spain. p. 98-99
8. Ministry of Health of Peru. Technical Standard for Health Care Quality
Audit. NT N° 029-MINSA/DGSP- V.01. 2005
9. Gutiérrez J, Esquén O, Gómez E. Compliance level of Nursing records in
the Obstetrics and Gynecology service of the Madre Niño San Bartolomé
National Hospital, 2012. Scientific Journal of Health Sciences. 2014;7(1):51-
56
10. Cedeño K, Cevallos S. Quality of nursing records made by the personnel
who work in the surgical and clinical sub-processes, Dr. Verdi Cevallos
Balda Portoviejo Regional Hospital December/2013 –May/2014 [Bachelor's
Degree]. Technical University of Manabi; 2014.
11. Bautista L. Nursing records. Science and Care Magazine. 2015;12(2):5-9
12. Magaly, VT Profile. Models of nursing notes. Nursing SOAPIE [Internet].
[Link]. [cited June 26, 2021]. Available at:
[Link]
ANNEXES:
Annex 1: Model of Nursing notes
Annex 2: SOAPIE systematic method
Common questions
Powered by AINursing notes are integral to the professional development of nurses as they provide a framework for reflective practice and evidence-based care. By meticulously documenting patient care, nurses reinforce their understanding of clinical practices and enhance their decision-making skills. This practice not only improves clinical competence but also contributes to academic advancement as nursing notes serve as educational tools in training programs and research . They help nurses develop a culture of quality, reinforcing the professional standards required for providing high-quality care and facilitating professional growth .
Nursing notes play a crucial role in legal proceedings as they serve as legal documents that provide evidence of the care given to patients. To fulfill this role, nursing notes must be detailed, orderly, and devoid of erasures, amendments, or blank spaces. The information must be objective and truthful, accurately reflecting the patient's condition and the care provided. The notes need to be comprehensive and logical, documenting the procedure performed, patient health condition, adverse reactions, and all care provided during hospitalization . These standards ensure the notes can legally support the nursing staff in case of lawsuits .
Nursing professionals often face challenges such as time constraints, high patient-to-nurse ratios, and inadequate training in documentation standards, which can lead to incomplete or low-quality nursing notes . These issues can be addressed by implementing regular training programs that emphasize the importance and techniques of precise documentation. Institutions can also invest in electronic health records that streamline the documentation process and enhance accuracy. Additionally, establishing a culture that values and recognizes quality documentation can motivate nurses to maintain high standards in their records .
Nursing notes facilitate communication among healthcare providers by ensuring that detailed and systematic records of patient care are available throughout a patient's treatment journey. This documentation allows different providers to easily understand the patient's condition, care plan, and any changes that have occurred, which supports coordinated and efficient care delivery . Poor documentation, on the other hand, can lead to miscommunication, which increases the risk of errors, misinterpretations, and adverse events, ultimately compromising patient safety and care quality . Quality documentation is essential for enabling effective interdisciplinary collaboration and improving patient outcomes.
Nursing notes serve several key purposes. They are a written tool that provides a concrete, objective, and understandable record of the patient's care, activities, observations, and decisions during the healthcare process. These notes support patient care by ensuring quality and continuity of care, improving communication among healthcare providers, and preventing errors . Furthermore, they serve as a legal document for potential litigation and are essential for retrospective evaluation of care quality during the hospital stay . The notes also contribute to academic and professional development by serving as a valuable resource in undergraduate and graduate training and research .
Accurate nursing documentation is crucial for ensuring continuity of care and patient satisfaction. It allows for seamless communication between different healthcare providers, ensuring that patient care plans are consistently followed and adapted as necessary . Precise records help track the patient’s progress, enable timely interventions, and reduce the likelihood of errors, which enhances patient safety and satisfaction. Having a clear, accurate documentation also aligns with the World Health Organization's standards for high-quality professional excellence by efficiently using resources and minimizing patient risks .
The SOAPIE method enhances patient care quality by providing a structured framework for documentation that facilitates comprehensive and systematic recording of patient information. By following the SOAPIE structure—Subjective data, Objective data, Assessment, Plan, Intervention, and Evaluation—nurses can ensure that all aspects of patient care are covered, promoting thoroughness and consistency in documentation . This method helps in clear communication of patient conditions, aiding in the development and execution of effective care plans. Additionally, it allows for continuous evaluation and adjustment of care plans, which is critical for meeting patient needs and improving outcomes .
Florence Nightingale significantly influenced modern nursing practices by emphasizing the importance of valuing care beyond just administering medicines. Her approach defined nursing as putting the patient in a position conducive to natural healing, which underscored the necessity for prepared and intelligent nursing work . Nightingale's emphasis on quality and statistical validation laid the groundwork for the professionalization of nursing and the systematic recording of patient care. This has evolved into the structured nursing notes we use today, serving as a foundation for quality assurance and evidence-based practice .
A well-documented nursing note following the SOAPIE method should include the following components: Subjective data, which are the patient's expressions recorded in quotes; Objective data, based on the nurse's observations; Assessment, which involves analyzing and interpreting the data; Plan, which outlines the proposed care strategy; Intervention, detailing the actions taken; and Evaluation, which reviews the outcomes of the interventions to determine if the expected results were achieved . This structured approach ensures comprehensive and accurate documentation, which supports quality patient care and continuity in treatment plans.
Nursing notes contribute significantly to healthcare research and education by providing a valuable source of real-world data on patient care practices and outcomes. These notes can be analyzed to study trends, evaluate the effectiveness of interventions, and develop evidence-based practices . In education, nursing notes serve as a practical tool in teaching students about patient assessment, care planning, and professional writing skills. They help bridge the gap between theory and practice, allowing students to learn from real case studies and fostering critical thinking and analytical skills .