Learn the basic rules and structure of nurse’s notes
urses notes are simple pages with lines at the top reading: nurses notes or progress notes but don’t get deceived. The information you write in these pages are legal documents. There are times when you do need to write and others you don’t. What you write or fail to do so, is important. But equally important is to understand who you’re writing for, and why and when you need to write. Confused yet? Read on.
Here’s some basic rules
Rule # 1 who are you writing for
When you write, you are doing so because you need to communicate something to someone. In the case of nurse’s notes, your target audience is a legal entity: the state; your boss or a lawyer. When writing your documentation keep that idea in mind. Write in such way that information cannot be misconstrued. Everything you write should not invite any further questioning if possible. Never write open ended statements.
It it is all about documentation.If you don’t document, it doesn’t exist. If you gave the right medication but documented the wrong one – you gave the wrong medication. You are documenting the work you did so you can prove you did the work. Likewise you are documenting events that happened so you can also prove they did happen. So nurses notes among many things are – proof of your work.
Rule # 2 Why you need a note
Some nurses are under the impression, the more they write the better. But pay little attention to why they need to write in the first place. Ask yourself why do you need a note. That way you’ll set yourself in the right direction because you’re are looking at the whole picture. You are evaluating the:
- the importance of given situation
- the possible consequences of the situation
- what it will take to address this situation
- what should be brought to attention
Think before you write. Nursing documentation cannot be erased; once you write a note it is there forever. 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 is, the more you should think before you write. If in doubt ask other nurses or your DON before you start writing.
Sometimes you deliberately omit writing a note. You should critically think and prioritize what needs to be documented. Remember, you are the nurse in charge. Use your own judment. You have to protect yourself, protect your employer and protect your patients.
Rule # 3 Keep your dates and times correct
This rule is seldom talked about but very important. Keep you timing correct. When incidents happen timing is very important; they are crucial marks that validate, illustrate and punctuate the events you’re documenting. You might right excellent notes but if you don’t document when they happened step by step they can be misconstrued and tell a different story. This is somewhat neglected but once you go through a serious situation you’ll know how important it is to stamp the time when anything and everything took place. This is specially important when there are time sensitive matters, like given medication that has time sensitive issues.
Structure of nurses notes
- Find out if documentation is needed
- What did you do about it
But don’t limit yourself to a cookie cutter idea. There are several ways to write a note, but it makes it easy if you apply these four principles. This is basically your regular SBAR but configured a little differently.
Breaking down even further
- Decide if you need to document an event
- Describe what happened
- Provide your clinical/nursing assessment
- Explain what you did about the situation
1. Decide if you need to write a note
This is the most important step and requires critical thinking. There are times you absolutely need to document and others you are better off not writing anything at all. Redundant and useless information can be confusing and counter productive.
Remember that 99% of the time, no one will ever read these nurses notes; only when something goes wrong they might be reviewed. Like in the event of a law suit.
If a patient sues the hospital because of some suspected wrong doing, your notes will be examined under a microscope and every word you wrote or didn’t write could put you and your employer in jeopardy.
Don’t write a note about a situation if you can’t follow up with. Remember that every important situation you documenting must have a follow up. If you can’t follow up, consider not writing anything at all. Writing an note also mean you’ll have to make sure that the next shift will follow up with. In a way you should evaluate if a situation is important or not by evaluating the amount of time and resources you have available to deal with this situation. If something is really serious you certainly have the time, if you’re not sure then it might not be so important. This is part of your time management and prioritization skills. The bottom line is: Don’t start something if you cannot finish. Notes are powerful, use it wisely.
Make a list of significant events, better yet ask your DON what are the usual events the unit or facility are looking for and what kind of documentation is needed. They might vary from place to place. In some institutions there is more scrutiny placed on certain events then others. So you first check with the culture of your workplace. Always check everything with your DON You’ll never get in trouble by asking, but you will if you don’t.
There are several situations that need documentation. They could range from a conversation with a patient to a change of condition or a incident completely unrelated to any patient, for example: someone walks in the nurse station and threatened a staff member. So is entirely up to your critical thinking. My advice is to only document important events that are unstable and have a potential to escalate into a bigger problem. Your documentation has the purpose of protecting you, the organization you work for and the patient. The core value of your nurses notes should be the provision of accurate, non judgmental, and useful information for anyone who needs to learn about a significant event in the past. Let me give you an example.
Your documentation is your only weapon when you’re alone out there. You want to document situations that are important and could escalate or complicate and you are responsible for. Every note you start should be viewed as a case you open and you keep adding more notes to it. Is really up to you to decide what is important. No one can tell you not to write a note, even though computer charting encourage you to just fill bubbles. Nurses notes can be seen as a right in self defense for situations that could potentially become out of control and damage you, your employer or the patient. Take charge.
Even though you don’t have to write about every single thing. You should keep a constant and regular writing that will reflect your work – kind of like you are keeping a diary of your work. Do that for each patient. You don’t have to write about every single thing but you should have samples of everything your touch. The more your write the more protection you’ll have.
2. Describe what happened
Once you decide to write about a case (something that happened) you want to start by simply stating what you’ve found. This is basically the first part of your documentation. It does not have to be pretty. Of course all words should be correctly spelled but it does not have to be pretty writing. What did you see? Describe the situation in a few words. Leave nothing important or significant out of your description. Don’t give any opinions, at this point you are a impartial observer. Describe exactly what you found and pay attention to the big picture.
Here again you have to use critical thinking. Not only you will not register your personal opinion but you will also not register other people’s opinions. If a patient was upset and came up with a story that was not true such as “my mother was seating in a pool of blood” don’t quote her story – only say “the patient was upset” by registering what the patient said you are officially creating doubt and validating an false scenario. Remember, If you didn’t document it doesn’t exist, be smart on how you communicate.
You should write your statement in such way that it does not lead to false or misconstruing of the facts at the same time it does no directly incriminate anyone. You never know the intent of those who will read your notes. If you have a serious incident ask another nurse to go over the note with you. Two thinking heads are always better than one, remember team work. Nurses notes are particularly powerful when all nurses work together and protect each other.
Your description should leave no questions to be asked. Always include all the crucial information concerning the event you are describing. For example: you write “the patient was complaining” it must be followed by – what was the patient complaining about. In other words your text should stand alone and have no open ended sentences. Anyone reading should have access to all information necessary to reconstruct the situation and not to have to ask any questions. In a court of law you’ll never remember what happened that night 2 years ago so add it while its fresh.
Your description of the situation is just a description of what happened as raw as possible, no judgment, no clinical assessment, and by all means add date and time.
3. Your clinical assessment
Because you are a nurse and a health care provider you’ll now assess the situation as a clinician. This is when you can actually give your opinion based on scientific data you collect. There is a critical difference between what happened and your clinical assessment. What happened is the raw data containing the basic elements of a situation. Your clinical assessment contain information you’ll will use to make recommendations and also justify your actions or non action.
What did you find as a clinician? How the situation affects the health care environment. How was the patient affected. Now is the time to register what you found and list all your findings. If the patient had a change of condition, what was the extent of the change, vital signs, what is the patient experiencing, and all other items of relevancy. In this assessment you can start by listing all your clinical findings and.
When assessing think of
- Vital signs
- Progress notes
- Health history
4. What did you do about it
This is a very important part of your note. Your own documentation of what you did to remedy, improve, and secure, the situation you are writing about. Your actions or recommendations will be based on your clinical assessment as well as you judgment as an RN. So when you produce your assessments have in mind that they must support and evidence your final actions (i.e. what did you do about it and why).
If you’re documenting something beyond your scope make sure you document that you let others know about and you have the confirmation that you did contact them. If is something that need to be followed up by the next shift, make sure you document that you informed the next shift. i.e. (next shift have been notified)
“What did you do about it” is a point everyone will be looking for when documentation is backtracked. No one wants the do nothing approach. Always do something!
Good documentation is an art and is not about producing beautiful writing but creating documentation that speak for itself. Good documentation should be accurate and leave no desire for further questions. Remember – If you did something but didn’t document you simply didn’t do it.
Types of Nursing notes
There are many types of nursing notes. They all have similarities because they are the documentation of something. But they can have different tones, and it will pay off to have that in mind. They have different emphasis and choices of word. Think of them in categories. It can make your work faster and more accurate because you already know which direction you need to go. I created some usual scenarios list that are common in any nursing floor. You can use them as a cheat sheet structure for your collection of notes.
- Ongoing progress notes
- Health notes
- Incident notes
- Behavior notes
- Communication notes
- Death notes
Ongoing documentation notes
These notes are just routine documentation. It is a summary of what you do for your patients on regular basis. Even though there might not be any significant events to note; you should 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. Remember if you didn’t document it didn’t happen. Chart frequently and every day. In a way is like a diary of your work. You should at least make one of these type notes a day. Nurses don’t always have time to do these because there might be some other more important notes to write. As a whole they are important because it is a validation of your work, or rather a history of how you work.
Ongoing documentation note sample
Pt is resting in his room. AO X4 no s/s of pain, distress or SOB. Pt ate < 75% of his daily intake and show signs of improvement as noted for being more active. Pt was encouraged to participate in PT today. Pt was up in the wheelchair x2. Dressing change today per order. All medications well tolerated, call light within reach. VS 146/74 98.2 76 18 97% RA
This is a type note you make when there is some change. Something important did happen or changed with your patient. A change of condition or something you did, like a change of catheter, or an IV injection. You basically want to document an important action you carried out. You used sterile procedures. You want to make sure you document what you did and what you didn’t do why you didn’t do it. Health notes can also include, admission notes, discharge notes, fall notes.
This notes are the ones you must pay lots of attention to. Incidents can get complicated and filled with critical details. Is important that you pay extra attention to time stamping and the order of events clearly.
My tip here is that as you notice there is an incident with a patient; 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. An incident is usually something that is unusual and have implications and consequences in the future, either to the RN, the facility or hospital or the patient. These are the type of notes that are most likely to be reviewed in a court of law. So, make sure you write them with the idea that a sharp lawyer will be reading and looking for holes.
Behavior notes are much like incident notes but with a difference. While incident notes are usually accidents or unpredictable events. Behavior notes are 100% psycho-social. They have to do with people usually making threats to the security of others.
So, the emphasis is on protect yourself and your boss. 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. The minute I see there is a new patient with behavior issues I begin to write a book about it. I record every and anything suspicious they say and do. If he ever reports you to the state you’ll have a collection of notes that will completely disqualify him from building any case against you or your boss. Unfortunately, this is the only way you must defend yourself.
Communication note are simple notes you are just letting other members of staff know about some information. These are simple notes but if the matter is of importance they also can become very important. Simple things such as: a certain fax has been sent; a patient needs to be ready to be picked up tomorrow morning at 0900.
These notes are only notes. No need to get fancy here. You are just informing other staff of internal tasks. But having said that; you should always post lots of these notes as you co-workers will appreciate. Failing to post them can also get into a lot of trouble; it obviously depends on the matter at hand. For example, if you had something important to tell the next shift and you want to make sure it is followed up – write a communication note. By writing these notes, you’ll make sure you don’t get in trouble with your staff.
Death notes can be quite simple but also very serious. If a patient is on comfort care or hospice it is simple. If a patient was not expected to day, it is a different story. In the first case, all you must report is 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 a extensive two page report. Don’t omit any details and time stamps. Document everything you did, everything you didn’t do and why you didn’t do it. For notes like this never write it alone. Always have your DON to sit down and write it with you. I’ll guarantee you that if you try to write alone you’ll forget some crucial information and latter should do a late entry.
Style and terminology
Nurses notes should be similar to police reports and lawyer’s writings. They are technical writing and have a preference for some keywords. The writing is focused on the content, in other words – the important information must be there and it hardly matter the order, or punctuation. Spelling however should be impeccable. Correct syntax also is not that important, if you have the time to do a better job its OK but I’ll guarantee you wont.
Words and sentencing
There are some words and sentencing that are standards in nurses notes. It is a good idea to have a stash of these in your bin so you can quickly write your notes.
Things you can always say you did (if you didn’t do I don’t want to know)
- call light is within reach
- the patient was educated about the schedule
- the patient verbalized understanding instructions
- the patient was fed dinner on admission
- the patient was satisfied and didn’t have further questions
- bed was left at lower position / bed down
- room clean and clean set of sheets in bed (on admission)
- pt is AOx3
- no s/s of distress, pain or SOB
- vital signs 138/73, 67, 97.1, 18, 97%RA (please don’t ever use WNL, it means nothing)
- the patient is able to make his needs known (it means: the patient knows what he is doing)
- the patient is not able to make decisions
On abnormal assessments
- patient was found on the floor
- the patient had an witnessed fall
- the patient is non compliant (it means that he does not follow instructions)
- the patient is at risk for fall
- the patient has eloped the facility (it means the patient leaves without having permission)
Nurses notes examples
You can Google “nurses notes examples” and will see many different samples, or you can look at my samples above. But if you just trying to copy somebody else work without knowing what you are doing – you are basically wasting your time. Invest time understanding why you are supposed to write a note. Think of what kind of information others will need to know about what happened. If you know that by heart, you’ll never need to look at another nurse’s work. Know the above and you can’t go wrong. Remember, is not about how long or how pretty you write; its about the content of your note relative to the situation.
Image credit: flickr.com