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Taking accurate nurses notes is one of the most important parts of caring for a patient. Nothing matters more than providing clear and detailed information about a patient's condition and their symptoms on their chart. Your observations make it easier to determine what medical treatments a patient needs without serious mistakes being made.
You should keep in mind a few core guidelines when you write notes on any patient:
Always use a consistent format: Make a point of starting each record with patient identification information. Each entry should also include your full name, the date and the time of the report.
Keep notes timely: Write your notes within 24 hours after supervising the patient's care. Writing down your observations and noting care given must be done while it is fresh in your memory, so no faulty information is passed along.
Use standard abbreviations: Write out complete terms whenever possible. If you must use an abbreviation, stick to standard medical abbreviations familiar to other nurses or the attending physician.
Remain objective: Write down only what you see and hear. Avoid noting subjective comments or giving your own interpretation on the patient's condition.
Note all communication: Jot down everything important you hear regarding a patient's health during conversations with family members, doctors and other nurses. This will ensure all available information on the patient has been charted. Always designiate communication with quotation marks.
Ignore trivial information: Everything included in your nurses notes should directly relate to your patient's health. Do not note information on your chart that does not pertain to their immediate care.
Keep it simple: Notes are not meant to be a work of art. They are designed to be quickly read, so nurses and doctors on the next shift can be caught up to speed on a patient. Focus only on specific information relevant to symptoms you are charting. Do not go into depth on the patient's medical history.
Write clearly: When you do handwritten notes, make an effort to keep your handwriting clear and readable. Illegible handwriting can lead to a patient receiving the wrong medication or an incorrect dosage of the right medication. This can have serious, or even fatal, consequences.
Standard nurses notes usually include an opening note, middle notes and a closing note. In these notes, you should note any primary or secondary problems a patient is experiencing. Record things like blood pressure, heart rate and skin color that can offer insight into these issues.
Make a record of any assessments you have administered during your shift. Indicate if more tests are needed and include a probable diagnosis of their condition.
Always note what medications the patient has been prescribed. List all medications the patient has been given, along with dosage and how the medicine was administered.