NURSES NOTE

INTRODUCTION
Nursing notes can be sometimes called narrative notes or progress notes but don't get confused.
The information you write in these pages are for the most part, legal documents. This sort of
documentation is essential for good clinical communication. Appropriate legible documentation
provides an accurate reflection of nursing assessments, changes in conditions, care provided and
pertinent patient information to support the multidisciplinary team to deliver great care.
Documentation provides evidence of care and is an important professional and medico legal
requirement of nursing practice.

Definition
Nurse's not is my written or electronically generated information about a chant that describes the
care or service provided to that client. Through nurse's note, nurses communicate their
observations, decisions, actions and outcomes of these actions for clients. Nurse's note is its
accurate account of what occurred and when it occurred.

Basic rules:
1. Know your Audiences: Anything you write should not invite any further questioning.
Never write open ended statements. In the case of nursing notes, your target audience is a legal
entity like: the state, your boss, a doctor, other nurse or a lawyer. Keep in mind whom you are
writing

2. What to write: Think before you write. Nursing documentation cannot be erased If you
make a mistake or forget something you can always write a late entry. But you can never delete a
note from the records. The more complex a situation, the more you should think before you
write. If in doubt ask, another nurse or your In-charge before you start and close the note. You
should critically think and prioritize what needs to be documented. Remember, you are the nurse
in charge. Use your own judgment. You have to protect yourself, protect your employer and
protect your patients. Before writing anything ask yourself following questions

 What is the focus of this note.

 Level of importance.
 What can be omitted/what cannot.
3. Date and Time: Every significant part of your story should be time embossed. Failing to
do so can create a contradictory story line and can damage someone's life critically. Time
recording is especially important when you are trying to document a complex event. You proper
record can save once life and can also ease doctor and other staff to take right decision at right
time

4. Writing of Notes: Not all the notes or reports are same, some notes can be written quickly,
others may take hours complete. If you are documenting that a patient had a fever that was
relieved with paracetamol is one thing. But if you are documenting an emergency or a behavior
situation involving bodily harm it is quite another. Therefore, it needs proper cane, review each
and every sentence carefully before submitting it.

5. Process
1. Patient assessment.

2. Plan of care.
3. Real time progress note.

Structure of nurses' notes

 Find out if documentation is needed.
 Situation.
 Assessment.
 What did you do about it.

There are seen ways to write a note, but it makes it any if you apply these four principles. This is
basically your regular SHAK but configured differently.

SBAR
1. Situation.
2. Background.
[Link].
4. Recommendation

Breaking down even further

1. Decide if you need to document an event.

2. Describe what happened.

3. Provide your clinical/nursing assessment.

4. Explain what you did about the situation.

Points to Remember
1. Remember that 99% of the time, no one will ever read these nurses notes only when
something goes wrong notes will be reviewed. Like in the event of a la sat or complaint.

2. Your description of the situation in fast a description of what happened as rate as possible, no
judgment, and by all moms add date and time.

3. When assessing think of

o Vital signs.
o Diagnosis.
o Medications.
o Psycho-social.
o Progress notes.
o Health history.
o Pain.
o Distress.
o SOB (Shortness of Breath).

Types of Nursing Notes

There are many types of nursing notes. They almost look similar because they are the
documentation related to same matter. However, they can have different tones which should be
consider while writing or composing any of these nursing notes. They have different emphasis
and choices of word and need of assessment.

Think of them in categories. It can make your work faster and more accurate because you
already know which direction you need to go. Here are some usual scenarios list that are
common in any nursing floor.

a. Ongoing progress notes

b. Health notes

c. Incident notes

d. Behavior notes

e. Communication notes
f. Death notes

a. Ongoing documentation notes

 These notes are just routine documentation.
 It is a summary of what you do for your patients on regular basis.
 Document what you did as a routine.
 It is just a progress note so anyone can know what is going on with a given patient.
 Chart frequently and every day, in a way is like a diary of your work.
 It is a validation of your work, or rather a history of how you work.

b. Healthy notes.
This is a type note use when there is some change • A change of condition or something you did,
like a change of catheter, or an IV injection.

It is basically, to document an important action you carried out. It is to make sure you document
what you did and what you didn't do, and why you didn't do it.

Health notes can also include:

a. Admission notes

b. Discharge notes

c. Fall notes.

c. Incident notes
-These notes are the most important one.
-Incidents can get complicated and filled with critical details.
-It is important that you pay extra attention to time stamping and the order of events clearly, ie,
date, time, condition and medicine.

-Start writing pocket notes as the events as the unfold.

- Incident notes can be a patient rapidly deteriorating condition; a fire in the room;

a fight between staff.

-These are the type of notes that are most likely to be reviewed in a court of law.

-Make sure you write them with the clear idea and record.
d. Behavior notes
 Behavior notes are similar to incident notes but with some difference.
 Behavior notes are considered as psycho-social notes.
 Be careful while writing these notes.
 Behavior is usually patients having bad behavior, aggressiveness events, attack events,
fights and threats to self or others.
 Patients with behavior issues must be payed close attention because they are usually the
ones who later will get you fired over some blatant lie.
 Record each and every minute you see there is a new patient with behavior Offer other
staff to help you recording these notes carefully.

e. Communication notes
 Communication note are simple notes you are just letting other members of staff know
about some information.
 Somehow, these notes called "over" locally in Pakistan.
 Example a certain labs has been sent; a patient needs to be ready to be picked up
tomorrow morning at 9.00 am.
 You are just informing other staff of internal tasks.
 By writing these notes, you'll make sure you don't get in trouble with your staff

f. Death notes
 Death m dh notes can be quite simple but also very serious.
 Report the time and manner of death what happened and the time of death, who you
called, when did you call etc.
 In the case of an unexpected death you note will have to write in-depth and long note.
 Don't omit any details and time records.
 Document everything you did, everything you didn't do and why you didn't do it
 Get help from supervisor or DON to sit down and write it with you.

Nurses note clearly describes:

1. An assessment of the client's health status, using interventions cared out, and the impact of
these interventions of client outcomes.

2. A care plan or health plan reflecting the needs and goals of the client;

3. Needed changes in the care plan.

4. Information reported to a physician or other health care provider and when appropriate. that
provider's

5. response, and

6. Advocacy undertaken by the use on behalf of the client.

Purposes of nurse's note

1. To facilitate communication

2. To promote good nursing care

3. To meet professional and legal standards.

METHODS OF NURSE'S NOTE

FOCUS CHARTING
With this method of documentation, the mase identifies a "focus" based on client concert or
behaviours determined during the assessment. I 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

Data: Selective and objective interim that suppose the stated fees or describe the list at the time
of a significant event of intervention.

Action : Completed or planned nursing intervention based on the nurses' assessment of the
Response. Description of the impact of the interventions on client cases.

SOAP/SOAPIER CHARTING
SOAP SOAPIER chanting is a problem-oriented apposach to documentation whereby the marve
identifies and hosts züent problems; documentation the fellaws according to the identified
problems.

Nurses note is generally organized according to the to the following headings:

S=alive data ( How does the client feel)

O=objective data (rare of the physical ex, relevant vital signs)
A=assessment (eg , what is client status )

P-plan( eg-does the plan stay the same? is a change needed)

I-intervention (e.g s-what occured? what did the nurse do?)

Evaluation.(e.g- What is the client outcome following the intervention?)

Revision (e.g., what changes are needed to the care plan?)

NARRATIVE CHARTING
Narrative method in a method in which nursing interventions and the impact of these
intervention client outcomes ne seconded in chronological order covering a specific time frame.
Data is recorded in the progress notes, often without organizing framework. Native charting may
stand alone or it may be completed by offer tools, such as flow sheets and checklist.

DO,S DON’T,S

[Link] that you have the correct chart before Don't chart a symptom, such as "c/o pain"
you begin writing without also charting what you did about it.

[Link] sure your note reflects the nursing

process and your professional capabilities.
[Link] legibly. [Link]'t alter a patient's record - this is a
criminal offense.
4. Chart the time you gave a medication the 3. Don't use shorthand or abbreviations that
administration route, and the patient's aren't widely accepted.
response.
5. Chart precautions or preventive measures 4. Don't chart what someone else said. beard,
used, such as bed rails. felt, or smelled unless the information is
critical. In that case, use quotations and
attribute the remarks appropriately
6. Record each phone call to a physician. 5. Don't chart care ahead of time- something
including the exact time, message, and may happen and you may be unable to
response. actually give the care you've charted.
Charting care that you haven't done is
considered fraud.
7. Chat patient care at the time you provide it

The following are some tips to keep in mind when charting Nurse's note

1. Follow these rules for charting .

  chart everything
1. Include observations. 2. Nursing actions.
 patients 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.

2. Be specific: avoid being general or vague.

3. 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 If you observe
changes in the patient, do not just chart them, but also notify the will subject the institution
and you to civil and criminal penalties .
4. Chart as you go. This is enter said than done physician.
5. If the physician becomes abusive or does not respond appropriately, notify the proper
administrative personnel to assist in resolving the matter.
6. If you nuke a mistake in chatina-correct it after the last entry you made-not where you should
have made it in the first place.
7. If you are asked to chart for someone else don't do it. But if you are able 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.
8. Above all, do not try to cover up a mistake. Be candid with both family, physician and your
institution.

Format of nurse's note

SL NO DATE TIME PROCEDURE SPECIAL SIGNATURE
REMAK

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 pursing process

 Assessment observation for signs of actual or potential problems.

 Planning: determining a plan of care targeting identified issues .
Implementation: the actions required for 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, do not wait until the end of
shift to record the days work.
- Charts are legal documents and should be accurate, concise, and complete .

- Never chart prior to acutally performing care (i.e 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 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 smit", 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.
 Conclusion
In conclusion, I chose a nursing career as a result of my past experiences. This allowed me to
gain essential qualities of what I believe determines a successful nurse. To remain on this
path to success I have established important goals that I attend to achieve in 5 years' time.
This includes attaining the main characteristics that define a successful nurse. My other goal
is to develop and maintain my professional nursing portfolio, followed by committing myself
to lifelong learning and continuing education in my nursing career. Giving back to my
community and providing ongoing medical assistance is the final goal that I would like to
achieve.

BIBLIOGRAPHY:-

 Vati. J. Nursing Management Administration for [Link]. and [Link]. Nursing. 2 nd Edition. New Delhi:
Jaypee Brothers Publication; 2023. Page no. 566

 Clement. I. Management of Nursing Services and Education. 2 nd edition. New Delhi: ELSEVIER
Publication; 2018. Page no. 484

 Jean Barrett "ward management and teaching" Konark Publishers PVT LTD pg no. 182-
195.

 Lally S. (1999) An investigation into the functions of muses communication at the inter-
shift handover Journal of Nursing Management, 729-736
Tripura College of nursing
HAPANIA, AGARTALA

ASSIGNMENT
On

Nurses note

SUBMITTED TO SUBMITTED BY
MRS. SANGITA DAS ASMITA TRIPURA

ASST. PROF. OF TCN ROLL NO. 01

[Link]. NURSING 3RD SEM