Essential Guide to Nursing Notes
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ScribdTranslationsEssential Guide to Nursing Notes
Translated by
ScribdTranslationsNURSING NOTES
It is a written record prepared by the nursing staff about observations of the patient, taking
into account their physical, mental and emotional state, as well as the evolution of the
disease and care.
Daily nursing care is often recorded on a special sheet assigned for this purpose, nursing
notes consist of two types of data:
Subjective
Goals
Subjective data tells us what the patient feels and how he or she expresses it. Objective data
include measures such as vital signs, observations by health care team members, laboratory
and radiographic findings, and patient responses to diagnostic and therapeutic measures.
GOALS:
Keep a written record of changes in the patient's condition.
Record the problems presented by the patient and the nursing care provided.
Collaborate with the doctor in the patient's diagnosis.
Serve as an information tool in the health field as a legal scientific document.
Research studies.
IMPORTANCE OF NURSING NOTES
Being able to evaluate the evolution of the patient's disease
It serves as information for the health team as a scientific and legal document.
You can identify the patient's needs
COMPONENTS OF NURSING NOTES
Date
Hour
Content
Signature
THE CONTENT OF NURSING NOTES MUST MEET THE FOLLOWING ASPECTS:
· Observations made at the time of patient admission
· General condition of the patient taking into account his physical, emotional state
· Reaction to medications and treatments
· Hygiene condition and care provided
· Objective and subjective observations
· Effectiveness of certain medications or treatments
· Teaching provided and support provided and assessment of learning.
The nurse's notes descriptively record the patient's progress. In some hospitals, nurse notes
typically record the following types of information:
Patient assessment by various nursing staff (e.g. paleness, flushing of the face, or the
presence of dark or cloudy urine.
Independent nursing interventions, such as special skin care or patient education, carried out
at the initiative of the nurse.
Dependent nursing interventions, such as medications or treatments prescribed by a
physician.
Evaluation of the effectiveness of each nursing intervention.
Measurements made by the doctor (e.g. shortening of a postoperative drainage tube).
Visits from health team members (e.g. doctor's office, physiotherapist, social worker).
In summary, a nursing approach indicates the reasons and activities of the nursing care the
patient is receiving, it describes what is happening to the patient as a result of the medical
diagnosis.
ESSENTIAL INFORMATION IN A NURSING NOTE INCLUDES THE FOLLOWING:
Any change in behavior:
Indications of strong emotions, such as anxiety or fear.
Major mood swings
A change in the level of consciousness
Any change in physical functioning such as:
Loss of balance
Loss of strength
Hearing or visual difficulty
Any physical signs or symptoms:
Be serious eg: intense pain
An increase in body temperature
Gradual weight loss
Inability to urinate after surgery
Any nursing intervention provided such as:
Medications administered
Treatments
Education
FOR A NOTE TO BE COMPLETE WE MUST PREPARE IT BY ANSWERING THE
FOLLOWING QUESTIONS:
How is the patient?
What do you observe and what does the patient report?
What does it do to him?
How do you leave it?
THE ASPECTS THAT ARE EVALUATED IN THE WRITING OF NURSING NOTES ARE:
Let them be systematic
Logics
Claras
Concrete
Precise
Briefs
Objectives
Narration with logical order
Vocabulary that is technical
Clear language
Avoid abbreviations
IMPORTANT ASPECTS WHEN WRITING A NOTE
All notes are made in dark ink so that the record is permanent and changes can be identified.
Notes must be legible and easy to understand. Typically blue is used for the morning shift and
red for the night shift.
You should never ask someone else to make notes that are your responsibility, as there may
be mistakes in the information. The note should be made by the person who provided care to
the patient.
Please write legibly and clearly. Illegible notes mean questionable information in a court of
law. Notes lose their value when exchanging information.
Record the information according to the sequence in which it occurred; the notes should
reflect the care provided in the order in which it was performed.
It is not advisable to rely on memory; make notes as soon as possible or take notes for
subsequent recording; there is a greater chance of making mistakes and omissions when
information is collected from several people.
Take frequent nursing notes and follow hospital procedures regarding the minimum interval
that should be kept between each note. This serves to prove that the patient was not
abandoned for a long time.
Record all significant information regarding the patient's condition and health status.
Omit words like One or he.
Please skip writing down the patient's name, each page of the record has the patient's name
and identification information. It is therefore understood that all the notes made are from the
same patient.
Fill out the entire line of each line of the printed form, marking a line along the blank space
left on the unused line.
Do not erase words or write over them, instead draw a straight line over the word.
ACCURACY
It is essential that the entries in the records are accurate and correct. Accurate notes consist
of exact facts or observations, rather than opinions or interruptions of an observation. Correct
handwriting is essential to the accuracy of the record. If you are not sure how to spell a word
you should consult a dictionary.
INTEGRITY
You cannot write down the data that a nurse obtains about a patient. However, the
information recorded must be complete and useful to the patient, doctors, other nurses and
workers involved in health care. However, the patient's history may be used to indicate the
type of administrative care. A complete note for a patient who has vomited (including time,
amount, color and odor of vomitus, and any other information about the patient).
Important Reminder:
From a legal standpoint, a well-written and timely nursing note will serve as a backup when
deducing responsibilities in the care of the patient. It can be a double-edged sword that can
save you or incriminate you, since the clinical record is a recording instrument with legal
implications and the nursing notes sheet is included in it.