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How to Write an Effective Nursing Note: A Comprehensive Guide
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Taking nursing notes is a regular practice in patient care. But writing nurses notes can be hard to know where to start, or how to make your notes stand out from the rest of your peers.
You want to be able to capture all the information you need in as few words as possible, but you also don’t want to leave out any important details.
Writing nursing notes, like building effective nursing care plans , is one of the core responsibilities of being a nurse, and learning how to write them effectively and quickly will set you up for success in your future career.
The most effective nursing notes include terminology, observance, detail, and readability. Whether you’re in clinicals or on the job, it’s important to understand why and how they’re crucial to providing quality care.
We’ll show you what goes into nursing notes and how to write them effectively for the best patient care.
But first, let’s get into how they’re relevant to charting.
The Basics of Nurse Notes
A nursing note is a detailed record that captures the comprehensive care provided by nurses. It includes the nurse’s observations, assessments, nursing diagnoses , care plans, interventions , and evaluations of patient outcomes ( ADPIE ).
Nurse notes are a key part of patient care documentation. They track the progress of a patient’s condition over time and facilitate communication between healthcare providers.
Accurate and thorough nursing notes are essential for delivering high-quality care and maintaining legal and regulatory compliance.
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.
Nursing Notes Examples
The following are four nursing notes examples varying between times of a patient’s admittance:
Acute Pancreatitis Nursing Note (Example)
Patient Name and Age: Kane Schneider, 33
Date: May 14th, 2022
Chief Complaint: The patient’s chief complaint is acute pancreatitis, which they developed after eating a large amount of greasy food. The patient also reports that they have been experiencing nausea and vomiting since they arrived at the hospital.
Diagnosis: Acute Pancreatitis
History: The patient reports that they have had similar symptoms in the past and have had several episodes of acute pancreatitis over the past few years. The patient has had all of their gallbladders removed in attempts to treat this condition.
The patient has not been taking any medication for nausea, but has been receiving IV fluids for hydration due to their vomiting.
Physical exam: Vital signs are stable — pulse = 72 beats per minute, respirations = 16 breaths per minute, temperature = 98.2 degrees Fahrenheit (F). Physical examination reveals a pale and diaphoretic person in moderate distress with abdominal tenderness on palpation in the epigastric area.
No jaundice or bruising is present on examination of the skin or mucous membranes. Abdominal distention is present with peripheral edema noted around the umbilicus area as well.
Urinary Tract Infection Nursing Note (Example)
Patient Name and Age: Elaina Hassan, 77
Date: January 29th, 2022
Chief Complaint: She has been experiencing fever, chills, and dysuria for two days.
History of Present Illness: Patient has previously experienced mild hypertension and heart failure.
Physical exam: Vitals – The patient’s temperature is 99 degrees Fahrenheit. The pulse is 100 beats per minute and regular. The blood pressure is 140/90 mm Hg.
Diagnosis: Urinary tract infection .
Assessment: She appears to be in moderate distress and is slightly tachycardic at 104 beats per minute. Patient demonstrates evidence of right lower quadrant tenderness on palpation as well as suprapubic tenderness on deep palpation. The patient’s urine dipstick test reveals 1+ blood and no white blood cells or nitrites present in her urine sample.
Evaluation: She has been treated with antibiotics and fluids, and can now urinate without discomfort.
Alcohol Withdrawal Nursing Note (Example)
Patient Name and Age: Willie Brandt, 41
Date: March 21st, 2022
Diagnosis: Alcohol withdrawal
Assessment: Patient was brought in by his family for alcohol withdrawal. When they brought him in, he was experiencing tremors, hallucinations, and confusion.
History: Patient has been drinking alcohol for 24 years, and his family noticed that he started to drink more heavily over the past few years.
Plan of care: Monitor vital signs every 15 minutes; check urine output every hour; administer IV fluids as ordered; administer medication as ordered (e.g., benzodiazepines); monitor electrolytes every 6 hours or as ordered; provide emotional support to patient and family; educate patient on how to avoid future episodes.
Upper Respiratory Infection Nursing Note (Example)
Patient name and Age: Jazmin Adkins, 25
Diagnosis: Upper respiratory infection, including rhinitis and pharyngitis.
Assessment: Patient presented with symptoms of a cold, including runny nose, sore throat, cough, and congestion. Symptoms have persisted for 2 weeks.
History: Patient works as a bartender at a local restaurant. Two evenings per week she works late into the night and does not get enough sleep; she also drinks alcohol on these nights (about 4 drinks).
She washes her hands frequently at work but does not use hand sanitizer before touching his face or putting his hands in his mouth. Patient often smokes cigarettes outside work hours and is always around cigarette smoke when out with friends or family members who smoke regularly.
General Tips for Writing Nurse Notes
When writing a nurse note, you must first think about what is important for the patient. But it’s also important to ask yourself: what’s important for the rest of your team?
Here are some simple tips for writing the perfect nursing note:
- Stay on point and be specific .
- Use shorter sentences when possible for easier reading.
- Include interdisciplinary team members .
- Use bullet points when possible (it’s much easier to scan through a list than long paragraphs).
- Sign each entry of your note with your name and credentials .
- Use correct grammar and spelling (and avoid autocorrect).
- Add new information throughout the patient’s visit .
- List a patient’s most important condition and its severity level (for patients with multiple conditions).
- Don’t forget the smaller details .
Include patients’ room and bed numbers at the top of the page (if you’re writing a note for an inpatient).
Take Your Nursing Learning to the Next Level
Taking nurses notes will be one of many, many job responsibilities you’ll have. You’ll be better prepared for success in your future work if you can write them efficiently, promptly, and with the maximum amount of detail.
You’ll have great nursing notes when you can quickly balance medical terminology, writing skills, detail, and observation.
To get all of that down easier and more efficiently, you’ll need a supplemental nursing school resource . SimpleNursing offers just about everything you need (study guides, question banks , assessments, and more) to perfect your nursing process.
Get the most out of your nursing courses and effectively put them together in your studies.
Unlock these resources with a free trial today and check out our NCLEX prep course as you prepare for your nursing exams .
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Career Advice > Professional Development > Upskilling and Promotions > How to Write a Good Nursing Note: Example and Tips
How to Write a Good Nursing Note: Example and Tips
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A nursing note describes the reason for a patient’s care, interventions, their response to the interventions, and their overall progress. Documentation is an integral part of healthcare , so honing this skill is definitely worth your time. Keep reading to learn about why nursing notes are important, tips for drafting your own, and a nursing note example.
Why Write Nursing Notes?
Nursing narrative notes facilitate communication between the healthcare team by detailing a patient’s progress. Having proof of a patient’s care can be useful for a variety of reasons. Oncoming nurses can read them to learn more about their assignments, the nurse who wrote the documentation can refresh their memory, and other healthcare workers can see the results of their interventions.
These notes are also used for other activities indirectly related to patient care, such as health insurance companies using them to assess the cost of care, or as a written record in the event that legal action is taken against an individual nurse or facility.
Nursing Note vs. Charting: What’s the Difference?
Nursing notes are a form of charting, but not all charting equates to a nursing note. Nursing narrative notes include more details than routine charting because they provide a general overview of the situation on top of patient progress.
Sometimes, charting places more emphasis on day-to-day changes. An oncoming nurse who’s unfamiliar with the patient will likely still have plenty of questions after reading the specific bits of information and data described in typical charting, but would get a more thorough idea of the situation from a nursing note.
What to Include in Nursing Notes
- Patient’s name and demographic information
- Objective and subjective data
- Interventions
- Outcome and evaluation
- Treatment plan
- Chief complaint
- Relevant history
- Medications
What to Avoid in Nursing Notes
- Non-specific wording
- Premature charting
- Symptoms without an intervention
- Personal assumptions
How to Write a Good Nursing Note
With all this background on what to include in a good nursing note example, you must be wondering about how to realistically draft one. Below, we describe how to write a nursing narrative note.
1. Be Specific and Detail-Oriented
Notes are an essential part of team communication. Coworkers will rely on your note, so it’s important for you to be as clear as possible. On top of that, nursing notes can be used as legal documents in the event of a malpractice suit . If you’re called to testify, you may not remember many details. You’ll have to rely on your documentation to do much of the speaking on your behalf.
2. Name the Colleagues With Whom You Interacted
Identifying your coworkers will save other team members time and energy. Instead of trying to figure out who did what, they’ll know exactly whom to approach when they have any questions or concerns about decisions regarding the patient’s care.
3. Keep It Simple
Short sentences and simple words are easier to understand than long sentences with elaborate language. This is especially important when you consider all of the stressors that can arise in healthcare environments.
4. Prioritize Objective Data
Your coworkers will be the most concerned with the facts, so ensure you include them in your note. The patient’s subjective experience is important, but information such as vital signs, lung sounds, and the patient’s visible appearance are the main drivers of the care plan . Why? Because they show what the body is communicating to you and what the patient may not be able to articulate.
5. Address the Chief Complaint
It’s important to describe progress, or lack thereof, regarding the reason the patient needs medical assistance in the first place. It can’t hurt to include other health-related details, but make sure to prioritize their chief complaint and anything directly related to it.
6. Remember to Sign Your Name
This seems like a no-brainer, but it’s a detail people may forget when in a hurry. For the sake of clear communication, it’s important for your coworkers to know who wrote the note. On top of that, a nursing narrative note isn’t complete without a signature.
Nursing Narrative Note Sample
Reading a nursing note example will help you gain a better understanding of what’s expected of you. Check out our sample below for some guidance.
XX/XX/20XX X:XXpm
The patient is a 64 year old female whose chief complaint is an exacerbation of chronic migraines. Patient reports an 8/10 pain level that decreases to 7/10 on the current prescription of 600mg of ibuprofen once a day. Patient states she feels nauseous, which is a common symptom of her migraine exacerbations. She describes the quality of migraine as a “stabbing, throbbing feeling.” Patient states she struggles with bright lighting and loud sounds because they worsen her migraines. In these instances, she says her pain score rises to 9/10.
Patient is AAOx3. HR=95 bpm, RR=20 bpm, T=98.6, BP=130/90, PO2=98%. Bowel sounds present and bowel movements remain regular. No complaints of impaired vision nor memory. Patient states there are no life stressors adding to her current migraine exacerbation. Patient states her sleep schedule is normal.
Mayowa Okumba, APRN, ordered a basic metabolic panel (BMP) and an MRI scheduled for tomorrow. Patient is aware and consents to these procedures. Will continue to monitor vitals and for any other signs of discomfort.
Cherise McDonald, RN
Nursing Note Useful Tips
Here are some tips to keep in mind to help you write a useful nursing note example of your own.
1. Record Key Details Throughout the Day
You’re responsible for juggling a lot of information, and it’s perfectly normal for small details to slip your mind. Those seemingly little details could be important to the big picture. Jot down any details that stand out to you as soon as possible.
Even if your reason is just a hunch, it can’t hurt to have it written somewhere until your mind understands why it was important. Write on something you won’t lose such as your report sheet or a small notepad. Just make sure you properly dispose of them to protect the patient’s private health information.
2. Create a System That Works for You
To avoid missing key details, build a nursing note routine. Do you prefer to include vital signs first or the patient’s chief complaint? Do you include objective data followed by subjective descriptions, or will both be intertwined throughout the note? Is there a specific nursing notes template you prefer? Having a system makes it easier to ensure you don’t miss anything.
3. Imagine Reading Your Own Note With Fresh Eyes
If you feel like you don’t have a clear picture of the current situation and impending actions after reading your note, why would anyone else? When you’re finished documenting, reread your note to ensure others can readily understand the most valuable information from your shift.
What Did You Learn From Our Nursing Note Example?
We showed you what to do, now it’s your turn! Strengthen your documentation skills so you can feel confident in your next role. Get connected with personalized nursing job matches in your location and specialty today.
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How to Write Patient Progress Notes [+ Example]
Table of contents.
Nurses are with the patient more than any other provider on the healthcare team, so you carry a big burden as a nurse to keep close watch over your patients and document every single detail of their care — no pressure though!
Below, I’m sharing what goes into good patient progress notes, from what they are to how to write them.
What Are Patient Progress Notes?
Patient progress notes are used to keep a record of a patient’s care when they are staying at a hospital. Nurses, doctors, physical therapists, and all other members of the healthcare team who provide care to the patient will document notes in the patient’s chart. All progress notes can be accessed by the members of the healthcare team in order to keep everyone aware of what is going on with the patient’s condition and care.
As a nurse, you will spend a lot of time reading patient progress notes as well as writing your own. Many nurses start their shift by reading through progress notes to get an idea of what’s going on with the patient and to prepare for their day of caring for them.
How to Properly Write Patient Progress Notes
Even though you won’t be the only healthcare provider writing patient progress notes, your notes as a nurse are some of the most important because you’ll be spending more time with the patient than any of the other providers. Here are some tips to follow to help you write effective patient progress notes.
Include essential information
There are essential pieces of information that should be included in every patient’s progress note.
Every patient progress note should include:
- Date and time
- Name of the patient
- Identification of the nurse who is writing the note
- An overview or general description of the patient
- Clinical assessment
- Any incidents that occurred
- Any changes noticed by the nurse (such as changes in the behavior, well-being, or emotional state)
- Any changes in the care (such as shift change to a new nurse or new orders placed by a doctor)
- Recommendations for further care
Use subjective and objective data
You should use subjective and objective data to craft a nursing note. Subjective data include information that the patient has provided, such as their pain level and their perspective. Objective data are what you have observed or gathered as the nurse, such as the patient’s visible state, their vital signs, or other clinical markers of their condition.
Make sure to distinguish between these two things when documenting. You can write things like “the patient states their pain level is a 10 and that they feel nauseous”. To gather subjective data prior to writing a nursing note, ask the patient questions about how they are feeling.
Use the nursing process as a guide
Whether you’ve just started nursing school or you’ve graduated, you’re likely familiar with the nursing process. I personally remember having this concept drilled into me as a brand new nursing student.
The nursing process is as follows:
- Diagnosis (nursing diagnosis)
- Intervention
The nursing process is a great guide for progress notes because it covers all bases. Remember, nurses can’t diagnose in the same way that doctors can, so you can discuss nursing diagnoses (such as pain or risk of infection) or you can note what the doctor has stated as the diagnosis.
Types of Nursing Documentation
Students and new graduates are often confused by all the different forms of nursing documentation. Here are some examples to help you distinguish them.
1. Charting
If you haven’t already, you’ll soon realize that charting is a big part of being a nurse. Charting includes all documentation of the patient’s care that is documented in the patient’s computerized chart. When charting patient assessments, you’ll use a computer-based spreadsheet to go through each body system and plug in information such as the patient’s pain level, how their lungs sounded, what their pulse felt like, etc. Progress notes are one aspect of charting.
2. Progress notes
Progress notes are the written notes that you’ll add to your patient’s chart when any changes occur. If the patient’s condition starts to decline or there are any changes in the patient’s care, then you will want to put a note in the chart so that it is documented. Progress notes are not only written by the nurse but by all of the providers who see the patient.
3. Handwritten notes
As a nurse, you will likely also keep some handwritten notes ( I know I did). Handwritten notes are a helpful way to jot down information as it’s happening if you’re not able to get to a computer right away.
4. Verbal communication at shift change
Another form of important communication as a nurse is the handoff report that you will give and receive at the end and start of each shift. This is an overview of each patient that is shared between nurses when a shift is changing. You’ll likely use your handwritten notes when giving your handoff report to the next nurse.
Why Is Documentation Important for Nurses?
Documentation is crucial for nurses because it helps to ensure proper patient care.
Nurses use patient progress notes to learn about new patients and their conditions, then they use progress notes to keep track of a patient’s care throughout their hospitalization. Progress notes are used by all members of the healthcare team to get an idea of how a patient is progressing throughout their hospitalization.
If for some reason a patient’s condition declines, documentation can be used to look back and determine whether any of the healthcare providers are at fault. In the rare case that a patient or their family decides to sue the hospital because of medical negligence, the nurses’ notes are some of the main documentation that will be used and looked at to determine what happened in the patient’s case. Many nurses use progress notes as a method to “cover themselves” in the case of a lawsuit. If you clearly documented every aspect of the patient’s care that you were involved in, you’re less likely to be blamed for whatever went wrong.
When Should You Write Progress Notes?
Every hospital will be a little different when it comes to how they prefer to have charting and progress notes performed. Some nurses enter progress notes at shift change, some write them with each patient assessment – it just varies. Ask your supervisor or the other nurses on your unit about how they prefer progress notes be written. If you have any issues with your patient, such as a decline in their condition or a transfer to a more critical unit, this would be a time when you should include a progress note.
Tips for Writing Effective Progress Notes
Writing strong patient progress notes is a skill that you will develop with time and experience as a nurse. In the meantime, you can follow some of these tips to help ensure that your progress notes are effective and informative.
Follow your workplace’s protocol
Asking your supervisor and other nurses on your unit can help you determine whether there is a specific format that you’re supposed to follow when writing patient progress notes. Every hospital will be a little different in what they prefer.
Use the facts
Try to be as objective as possible when writing patient progress notes. Include the facts and observations that are essential to help a person understand the situation at hand. Objective information ensures accuracy and understanding for anyone who reads the notes.
Keep it concise
Try to avoid including unnecessary information in your progress notes, despite possibly wanting to include it (such as stating that the patient called you a name or was rude to you). Adding anecdotal information to a progress note waters down the actual purpose of the note and pulls the attention of whoever reads it away from the important information. Not to mention, it is unprofessional!
Review the notes of other nurses
If you’re new to nursing (or still in nursing school) take some time to review examples of other nurses’ progress notes for their patients to get an idea of what a strong progress note looks like.
Example of a Patient Progress Note
Here is an example of a patient progress note that includes all the necessary information:
Date: 02/15/2023
This RN (Sophia) found the patient slumped over in bed. Upon assessment, the patient was found to be cold and sweaty. This nurse was able to wake the patient by tapping them on the arm and stating their name, but the patient remained in a disoriented, drowsy state. The patient’s speech was slurred and their eyes were glazed over. Vitals were taken. Blood pressure 125/45; Pulse 65; Blood glucose 50. This RN notified the physician, orders were given. Glucagon administered. Blood glucose rechecked and found to have increased to 100. The patient began to become more lucid and awake, speech became clearer. Will continue to monitor.
Final Thoughts
Writing strong patient progress notes is an essential part of being a nurse, but just like with any other nursing skill, it will take time and practice to get good at writing them. Do your best to be clear and concise and include all of the pertinent information when writing patient progress notes.
My name is Sophia. I am a Registered Nurse with experience working as a floor nurse on a Renal Care Unit and Hematology/Oncology Unit.
Further Reading
How to Practice Clinical Skills at Home
The Hardest Class in Nursing School
Writing Notes for Studying in Nursing School
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