Nursing Notes

Customer information record/

patient, of the observations made about
your health status, of the prescriptions
of nursing and its implementation,
of the evolution of nursing and others
care, among them, the execution of
medical prescriptions
(Nóbrega, 1980)
 OBJECTIVES

• Qualify the service provided, through

written evidence,
• Facilitate the conduct of audits;
• Attend to ethical-legal purposes;
• Serve as an important source of research;
• Promote good communication among the team;
• Maintain the continuity and efficiency of services
patient assistance.
 Evaluation of
Communication Assistance
Writing
Audits

Documentation Notes from Continuity

Historical Nursing of Assistance

Sources of Backup
Research Ethical-legal
 TYPES OF ANNOTATION OF
Nursing

Charts: SSVV control sheet

Graphic signs: Check (/) and circle (О) over the schedule on
nursing and medical prescriptions

Descriptive: Numerical - Values of measurable parameters

(Controls, Gains and Losses);

Written Narration - Record of the narrative form

from what was carried out, observed and/or reported by
patient or family member.
(Gonçalves, 2001)
 Ethical-legal dimensions of nursing notes

... nursing documentation is the duty of everyone

nursing team professionals.

... The incorrect, incomplete, falsified annotation or

inexistente em prontuário, dos fatos relacionados
to the hospitalized patient, it can characterize a
type of crime called Fraud
Ideological, provided for in the Penal Code, art. 229

(Oguisso, 2005)
It is to alter the idea of a document or its content, without
change its material form.
Omission - omits a statement.
Commission - inserts or causes to insert false or different declaration
from which it should be written.

The crime of ideological falsehood is constituted by "issuing, in a document

public or private, false or different declaration than the one
should be written, with the aim of harming rights, to create
obligation or to alter the truth about a legally relevant fact
relevant. Imprisonment.
(Penal Code, art 299)
Notes should be made, not by
fear of litigation, but because the greater
the beneficiary will be the patient, whose asset-
physical and mental health depends on the
skills of the health team and of
qualidade da assistência prestada”

(O'Driscoll, 1997)
 Code of Ethics for Nursing Professionals (Res. COFEn 311/2007)
Responsibilities and duties
Art. 25. Register in the Patient's Record the information that is inherent and essential to
process of caring.
Article 41. Provide complete and truthful written and verbal information necessary for
ensure the continuity of assistance.
Art. 54. To support the number and category of registration with the Regional Nursing Council in
signature, when in professional practice.
Art. 71. Encourage and create conditions to register the information inherent and essential to
care process.
Art. 72. Record the information inherent and essential to the process of care clearly.
objective and complete.

Prohibitions
Art. 35. Registrar partial and untrue information about the assistance provided.
Art. 42. Sign the Nursing actions that you did not execute, as well as allow your actions
to be signed by another professional.

Rights
Art. 68. To record in the medical record and in other specific documents of Nursing information.
related to the process of caring for the person.
 RECOMMENDATIONS FOR ANNOTATIONS
Patient identification
* Dates; times;
* Heading; no. COREN, function abbreviation at the end of the annotation

What is not visible, note "refers".

Registration made by the professional providing the assistance
Registration is preferably done right after the care.
It is recommended to have at least one written narrative per shift.
Do not leave blank spaces. Do not use a text editor. Pass a
line between the end of the annotation and the signature. Do not skip lines for another
annotation.
* Do not erase (use “I say”,.... “Without Effect”)
Only use abbreviations standardized by the institution.
They must be clear, objective, and concise.
One should not use assumptions, value judgments, or jargon.
 To maintain professional credibility regarding the
nursing notes, these must have:

• technical content;
• informação substancial;
• consistency;
• objectivity;
• clarity;
• acuity
• date, time, legible letter;
• signature or possible identification of the professional.

The patient's eventual objection to any care or medication must be

noted recording the alleged reason(s), even recommending
that the patient's own words be transcribed.
 CONTENT

Functions
physiological
Eliminations
Aspects
physicists Oxygenation, standard
respiratory
Signs and symptoms
Skin-mucosal integrity
Drain conditions, probes,
catheters, dressings, etc.
Psychosocial aspects

Calm, restless, tearful

 CONTENT

Movement Nursing actions

internal
All the care provided,
Arrival time at including the procedures
unit Incidents and measures
Forwarding sockets
Destination location, Patient's response to actions
objective of nursing performed
Departure times and
Preparation of the body in cases of
return
death with certificate at the UPA

Source: Cianciarullo, 2001

 General Rules

All notes must contain:

Patient identification: label
should be placed in the first annotation of the day

. The notes must always be preceded by a timestamp and made

in blue pen in all periods,

10:00 - Afebrile, eupneic, reporting pain with a score of 8. Communicated.

nurse Clara and medicated according to item 1 of the PM.
Coren-SP

. The red pen should only be used if standardized by

institution

Ex: 11:00 – Presented a fever peak of 39.2º C, with 2 pairs being collected.
blood culture. Medicating according to item 6 of the PM.@@@@ Coren-SP
 General Rules
Admission
Where to write it down?

. Specific print from the SAE

What to note?
. Schedule
. Who came accompanying
. General conditions (in a chair, on a stretcher, walking, presence of injuries,
venoclysis
. Orthoses and prostheses - it should be noted what they were delivered for
. Guidelines - regarding the unit, routine, and procedures to be carried out

How to take notes?

08:00 - Admitted to the unit coming from hospitalization in a wheelchair,

accompanied by his wife Mrs. Ligia, to undergo surgery for
videoarthroscopy. Fasting since 10 PM on the 29th of February. Instructed regarding the
operation of furniture, use of telephone, calling system, and preparation
for the surgical procedure to be performed at 2 PM, reinforcing the fasting.
Coren-SP
 General Rules
• At the end of each annotation, the professional stamp and signature must be affixed.
in case of your absence, you must write the full name, Coren number and the acronym of the
Function:

Ex: 12:00 - Showed improvement in fever symptoms, temperature of 36.2ºC.

Coren – SP TE

. Do not use correction fluid and avoid scribbles. In case of a mistake, use 'I say' in between.
commas:

Ex: 17:00 – Presented 1 episode of vomiting, being medicated with item 5 of the PM,
I say, item 6 is communicated by nurse Lúcia.@@@@ Coren-SP

. In case of incorrect and extensive notation, write next to the notation, WITHOUT
EFFECT, recording in the first subsequent line with the time, that the annotation
the previous one is incorrect and/or does not correspond to that patient:

10:00 – 1st PO of total hip prosthesis, afebrile, eupneic, reporting pain of

Score 8. Nurse Lucia communicated and medicated according to item 1 of the PM.
@@@@Coren-SP (WITHOUT EFFECT)

10:10 – The above annotation does not refer to the patient.@@@@ Coren - SP
 General Rules
Transfer
Where to write it down?

Specific SAE printout

What to note?
Type of transfer - whether medical or at request
Schedule
Responsible doctor
Clinical conditions of the patient
Destination
How to take notes?

Ex: 16:00 - Transferred to the intensive care unit after showing signs
of hypovolemic shock on stretcher, unconscious with BP 70/50 mmHg,
monitored with pulse oximeter - HR 98 and Sat 92% with O2 catheter at 3
liters/min, at the request of Dr. José Paulo, being accompanied by him and
by the unit nurse. Maintaining venous access in the right arm on the 2nd day of
puncture with Ringer, @@@@Coren-SP
 General Rules

High
What to note?
• Type of Discharge – medical or at request
• Schedule
• Responsible doctor
• Patient's clinical conditions
• Destination
• Guidelines

How to note?
11:00 - Discharged from the hospital accompanied by family in a wheelchair,
aware. Focused on home care, medical prescription,
delivered exams.@@@@Coren-SP
 General Rules
Death
What to note?
Care and procedures previously performed - service of
emergencies and emergency (CPR)
Schedule
Doctor who confirmed
Time when devices and gases were turned off
Dressing performed
Materials used in the preparation of the body
Referral to the morgue and time
Note: Inquire about the religion of the deceased before preparing the body.
patient and if the person is Jewish, do not perform the tamponade of
body, only the preparation and hygiene
How to take notes?

4:00 PM - Emergency medical system activated after cardiac arrest confirmed

installed. Cardiopulmonary resuscitation procedure performed by Dr
José Paulo and the nursing team in the unit for 20 minutes without
Success. Death declared at 16:20 hrs. Communicated to the Admission department for
contact the family. Body preparation completed – SNE removed,
SVD, chest drain, intravenous devices, and dressing performed in the area.
sacra. @@@@Coren-SP
 General Rules
Venous Access
Where to write down?

Specific SAE print

What to note?
Local
Type and number of the intravenous device
Conditions of the puncture site (skin and local venous network)
Number of punches
Incidents

How to take notes?

Ex. 16:00 – Punctuated peripheral venous access in the left upper limb with Jelco number 24, location of
insertion with intact skin.@@@@Coren-SP

OBS - In cases of loss of access, the reason for the exchange must be justified.
Ex.2 17:00 - Surgery rescheduled in MSD due to the presence of phlebitis in MSE,
being used 1 jelco number 20 and 1 jelco number 22, due to the difficulty of the puncture by
hair fragility. @@@@Coren-SP
 General Rules
Nursing Assistance in Washing (Gastric, Intestinal)
Where to write it down?

Standardized print for the SAE

What to note?
Tipo ( gástrica / intestinal); Nº

Intercorrências: Resistência na passagem da sonda; sangramentos

Clinical conditions of the patient - before, during, and after the procedure
Guidelines – regarding positioning in bed, rest and requests to
nursing

How to take notes?

Ex. 14:00 - Presents abdominal distension and pain with a score of 6. Observed by
physical examination, hyperresonance on percussion. SNG passage n. 22 performed, no
intercurrences and keeping the system open up to the 2nd Order, Aimed at maintaining
rest in bed and request nursing whenever necessary.
Coren-SP
 General Rules
Administration of Medications
• When preparing the medication, place a dot next to the medication time.
medical prescription, avoiding double dosing or non-administration of
same.

• Circle the medication time and note the reason in the designated space for it.
nursing notes (SAE printout)
Ex: 10
10:00 - Item 3 of the PM at 10 o'clock was not administered due to refusal.
patient. Informed Nurse Raul.@@@@Coren-SP

• Check and initial the time of the medication administered during the shift.
Ex:
10 Rita

Article 64 - Sign the nursing actions that were not performed, well
how to allow another professional to sign what they executed.

Code of Ethics – Prohibitions

 General Rules
Vital Signs Control
Where to write it down?

• Specific control sheet of the unit

How to take notes?

• Date and time must be filled in with a red pen and the other fields
in blue.
• Any and all identified abnormalities must be recorded with a colored pen.
red.
• All occurrences must be reported in writing (dissertation-style).
Ex Data Hour Temp F.C. F.R PA Score – Main goal

21/10 08:00 38.2 80 16 12/8 0

21/10 08:40 36.4 78 16 12/8 0

08:00 - Presents fever peak, informed Nurse Luiza, blood culture collected and medicated accordingly.
item 2 of the PM.@@@@ Coren - SP

09:00 Showed improvement in the fever condition.

 General Rules
Elimination Control
Where to write down?
Specific control sheet of the unit
What to note?
Diuresis
In the case of patients without prescribed control, the presence and/or absence must be noted.
control sheet.
Patient with prescribed diuresis control, record the volume in ml or weight in diaper in grams.
totalizing the 24 hours at 06:00, noting in a specific field.
The essay annotation must contain the characteristics of urine (color, odor, and appearance).

How to note?

Data Hour Diuresis

Ex .1 Data Hour Diuresis Ex.2
21/10 12:00 1000 ml
21/10 12:00 PRES
21/10 12:00 500 g
Attention Use the Acronyms
AC – Citrine Yellow
AE – Dark Yellow Ex. 3 - 12:00 - Presented diuresis of AE color, with odor
HE - Hematuria characteristic and with presence of lumps,.@@@@Coren-SP
P - Piúrica
 General Rules
Elimination Control
Where to write down?

Specific control sheet of the unit

What to write down?
Evacuation
Record the presence (PRES) and/or absence (AUS) on the control sheet.
Pediatric sectors, carry out the control of evacuation by the difference in weight in diapers.
grams (g).
The dissertative note must contain the characteristics of the feces (color, odor, and appearance).

How to take notes?

Ex. 1 Data Hour Evacuation Data Hour Evacuation

Ex. 2
21/10 12:00 200 g 21/10 12:00 PRES

Attention: Use the Abbreviations

Quantity:
+ - Pequena ++ - Média. +++ - Grande Ex. 3 - 12:00 - Presented evacuation SP in +/+++ of
M – marrom A – amarelo V – verde brown appearance, with a characteristic odor. @@@@Coren-
S – sanguinolenta L- liquida
SP
SP – semi-pastosa E – endurecida
 General Rules
Pain Control
Where to write it down?

Specific unit printout

What to note?
Location
Scale used
Score – valor numérico
Measures used
Comatose and confused patients, unable to respond, note NA in the space
intended for PAIN
How to note?
Fill in all the fields of the specific form, using the standardized legends.
Descriptive annotation of pain

Ex. 1 - 12:00 – Pain referee in abdominal region on the left flank in a 'sting' with a score of 8,
Statement Nurse Vera, medicated according to item 2 of the medical prescription.

Example 2 – 1:00 PM – Showed improvement in pain score - score 2 __________@@@@Coren-SP

 General Rules
Hygiene Care
Where to write down?

Standardized print for the SAE

What to note?
Local: (oral, bodily, intimate)
General conditions: skin coloration, edema, temperature, turgor, secretion, lesions
hydration and hygiene
Products used
Guidelines: before, during, and after the procedure
How to take notes?

Ex 1 9:00 Body hygiene performed with water and soap. Presents edema and hyperemia in
Gluteal region D, applied dersani, communicated to Lúcia. Patient and family oriented.
as for the need to change position

Performed intimate hygiene with water and soap; perineum intact, without edema and
lacerations _________________________________________________@@@@Coren-
SP
 General Rules

Dressing
Where to write down?
Standardized print for SAE

What to note?
Local
Aspecto – tipo de tecido (granulação, esfacelo,necrose), exsudato (seroso,sanguinolento,
purulent) and the peri-lesion skin
Products used
How to take notes?

Ex. 10:00 - Dressings performed on: insertion of double lumen catheter in SCD, wit
absence of inflammatory signs, keeping occluded with a conventional dressing. Dehiscence
abdominal, with the presence of necrosis and purulent exudate in moderate quantity with odor
acid, with 0.9% SF, maintained coverage with Zobec and fixed with micropore.
@@@@Coren-SP

Attention
All dressings must be included in the Nursing or Medical Prescription.
depends on the institution
 General Rules
Oxygen therapy
Where to write it down?

Standardized print for SAE.

Note: The installation or suspension of O2 treatment must be included in the PM.

What to note?
Type of device – catheter, mask or nebulization
Installed O2 concentration (liters/min.)
Installation and suspension schedule
Duration of use in all shifts
How to take notes?

Ex.1 10:00 - presented with dyspnea and desaturation of 86%, communicated to Nurse Patricia tha
directed the installation of an O2 catheter at 3L/min.
Ex.2 14:00 – Maintaining O2 catheter at 3L/min, saturating 93%.@@@@Coren-SP
Ex.3 20:00 - Oxygen catheter suspended by medical order Dr. Arthur. @@@@Coren-SP
 General Rules
Permeabilization of peripheral venous catheter
Where to write it down?

Standardized form for SAE.

What to note?

Location
Catheter insertion site: presence of inflammatory signs
Catheter permeability

How to take notes?

Ex. 1 10:00 Permeabilization of MSD CVP performed with 10 ml of SF

Coren - SP

Ex. 2 14:00 Maintaining a patent peripheral venous catheter in the right upper limb with good
permeability, without inflammatory signs
Coren- SP
 General Rules
Bladder catheterization for relief/delay

Where to write down?

Standardized form for SAE.

What to note?
Type of device
The discharge (characteristics, volume, frequency, odor)
Indication
Intercurrences – resistance, bleeding, material contamination
Clinical conditions during the procedure

How to take notes?

Ex.1 10:00 - Passed Bladder Catheter No. 14, without incident,

with drainage of 500 ml of urine, color AE, due to presence of retention
urinary, after reporting abdominal pain score 5. Showed improvement of
frame @@@@ Coren-SP
 General Rules
Isolation

Where to write it down?

Standardized print for SAE

What to note?
Tipo de Isolamento (contato, aéreo, gotícula)
Justificativa
Guidance - patient and family

How to take notes?

Ex.1 20:00 - Placed patient in contact isolation after positive culture

for multiresistant pseudomonas. Patient and spouse oriented regarding
need and care related to the situation. SCIH communication.
Coren-SP
Final Considerations

Carrijo, 2007
Cianciarullo, T.I; Gualda, D.M. Melleiro, M.M.; Anabuki, M.H. System of
Nursing Assistance: Evolution and Trends, São Paulo, Icone, 2001.

CARRIJO, AR. Records of a practice: nursing notes in

memory of nurses from the first Nightingale school in Brazil (1959-
1970). [dissertation]. São Paulo: School of Nursing of the University of São
Paulo; 2007.

Horta, V. Nursing process. EPU, 1970

Campadelli, M.C. Nursing process in practice, Atica Publishing. 1989.

Federal Council of Nursing. Code of Ethics for Professionals

Nursing. 2007 ([Link])

POSSARI, J.F. Patient chart and nursing records. 1st ed. São
Iatria, 2005.