The Role of Nursing Notes in Documentation and Charting

 

Nursing students learn charting (along with notes) early and often to better paint a picture of the patient’s health at the time of the visit or for the duration of the time. Charting includes the notes made by nurses and put into a computer.

Charting information is purely objective (IV site documentation, alarms, test results, etc.), and this nursing documentation is set up specifically for each working medical facility.

Making quick notes when evaluating the patient will enable you to chart more quickly and provide more accurate nurses’ notes immediately.

Read here to learn how notes and charts fit into the nursing process.


How Are Nurses’ Notes Used?
The first thing to know about nursing notes is that they’re not just for patients but also for nurses. Nurses notes fill documentation gaps between doctors, patients, and other providers.

The primary purpose of a nursing note is to track the progress of the patient’s condition over time.

You also may share notes with other team members, depending on their role within the department. This allows them to adjust treatments accordingly if necessary (e.g., increasing dosage).


How to Write Effective Nursing Notes
To write effective nursing notes, follow these guidelines:

 	
Verify the Correct Patient’s Chart: Ensure you are documenting in the correct patient’s record.
 	
Tell the Patient’s Story: Use your notes to provide a clear and comprehensive narrative of the patient’s condition and care.
 	
Document Real-Time Observations: Take notes in real-time or as soon as possible to ensure accuracy.
 	
Use Complete Phrases: Avoid abbreviations that could lead to misinterpretation.
 	
Document Safety Checks: Include any safety measures in place to protect the patient.
 	
Use Standard Acronyms: Familiarize yourself with common acronyms like SOAPIE (Subjective, Objective, Assessment, Plan, Intervention, Evaluation) and DAR (Data, Action, Response).

In short, you write everything you observe as a nurse and any significant medical information. Nursing notes include information about how the patient feels, what they need, and what’s going on with their health in a short, detailed summary.

When you put every piece of information together, make sure that everyone who needs to know about a patient’s care can access that information quickly and easily.
What To Write in a Nursing Note?
The information included in a nurses note varies depending on the facility’s needs and the type of care being provided. Nurses notes are often filled with abbreviations and medical jargon – which you and staff will know, but the patient most likely won’t.

Generally, here’s what you can expect from your nurse’s notes:

 	
General patient information: name, gender, age, address.
 	
Reason for their visit & Chief complaint: What they came in for and how long they’ve been under your care.
 	
Observations: What you’ve observed during your time with them (what they look like when they’re awake or asleep, their breathing patterns and heart rate, etc.).
 	
Treatment plan: A care plan layout based on the collection, analysis, and organization of nurses’ clinical data.
 	
History: Patient history including present and past ailments.
 	
Medication(s): Any medications given to the patient (including dosage details), along with medication history.
 	
Ending summary: An overall evaluation of their condition at the time of discharge.

Ideally, you should take brief notes while you’re in the same room as the patient, and add more detail as soon as you leave the patient’s room while the information is still current and fresh in your mind.