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Nursing notes

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this file contains information regarding Nursing notes: Patient progress notes, incident notes, death notes etc...

Nursing notes

  1. 1. NURSING NOTES SOHAIL AHMED SOLANGI 1 Nursing Notes Nursing notes can be sometimes called narrative notes or progress notes but don’t get confused. The information you write in these pages are for the most part, legal documents. This sort of documentation is essential for good clinical communication. Appropriate legible documentation provides an accurate reflection of nursing assessments, changes in conditions, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. Basic rules: 1. Know your Audiences: Anything you write should not invite any further questioning. Never write open ended statements. In the case of nursing notes, your target audience is a legal entity like: the state, your boss, a doctor, other nurse or a lawyer. Keep in mind whom you are writing. 2. What to write: Think before you write. Nursing documentation cannot be erased. 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, the more you should think before you write. If in doubt ask another nurse or your In-charge before you start and close the note. You should critically think and prioritize what needs to be documented. Remember, you are the nurse in charge. Use your own judgment. You have to protect yourself, protect your employer and protect your patients. Before writing anything ask yourself following questions  What is the focus of this note  Level of importance  What can be omitted / what cannot
  2. 2. NURSING NOTES SOHAIL AHMED SOLANGI 2  What is the most important information 3. Date and Time: Every significant part of your story should be time embossed. Failing to do so can create a contradictory story line and can damage someone’s life critically. Time recording is especially important when you are trying to document a complex event. You proper record can save once life and can also ease doctor and other staff to take right decision at right time. 4. Writing of Notes: Not all the notes or reports are same; some notes can be written quickly, others may take hours complete. If you are documenting that a patient had a fever that was relieved with paracetamol is one thing. But if you are documenting an emergency or a behavior situation involving bodily harm it is quite another. Therefore, it needs proper care, review each and every sentence carefully before submitting it. 5. Process 1. Patient assessment 2. Plan of care 3. Real time progress notes Structure of nurses’ notes  Find out if documentation is needed  Situation  Assessment  What did you do about it 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 differently.
  3. 3. NURSING NOTES SOHAIL AHMED SOLANGI 3 SBAR 1. Situation 2. Background 3. Assessment 4. Recommendation Breaking down even further 1. Decide if you need to document an event 2. Describe what happened 3. Provide your clinical/nursing assessment 4. Explain what you did about the situation Points to Remember 1. Remember that 99% of the time, no one will ever read these nurses notes; only when something goes wrong notes will be reviewed. Like in the event of a law suit or complaint. 2. Your description of the situation is just a description of what happened as raw as possible, no judgment, and by all means add date and time. 3. When assessing think of o Vital signs o Diagnosis o Medications o Psycho-social o Progress notes o Health history o Pain o Distress o SOB(Shortness of Breath)
  4. 4. NURSING NOTES SOHAIL AHMED SOLANGI 4 4. After you have written a note – read it, then read it again. Read it to your nurse buddy. Edit your nursing note – like you’re editing a paper for school. Types of Nursing Notes There are many types of nursing notes. They almost look similar because they are the documentation related to same matter. However, they can have different tones which should be consider while writing or composing any of these nursing notes. They have different emphasis and choices of word and need of assessment. Think of them in categories. It can make your work faster and more accurate because you already know which direction you need to go. Here are some usual scenarios list that are common in any nursing floor. a. Ongoing progress notes b. Health notes c. Incident notes d. Behavior notes e. Communication notes f. Death notes a. Ongoing documentation notes  These notes are just routine documentation.  It is a summary of what you do for your patients on regular basis.  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.  Chart frequently and every day, in a way is like a diary of your work.  It is a validation of your work, or rather a history of how you work.
  5. 5. NURSING NOTES SOHAIL AHMED SOLANGI 5 b. Health notes  This is a type note use when there is some change.  A change of condition or something you did, like a change of catheter, or an IV injection.  It is basically, to document an important action you carried out.  It is to make sure you document what you did and what you didn’t do, and why you didn’t do it.  Health notes can also include: a. Admission notes b. Discharge notes c. Fall notes. c. Incident notes  These notes are the most important one.  Incidents can get complicated and filled with critical details.  It is important that you pay extra attention to time stamping and the order of events clearly. i.e. date, time, condition and medicine.  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.  These are the type of notes that are most likely to be reviewed in a court of law.  Make sure you write them with the clear idea and record. d. Behavior notes  Behavior notes are similar to incident notes but with some difference.  Behavior notes are considered as psycho-social notes.
  6. 6. NURSING NOTES SOHAIL AHMED SOLANGI 6  Be careful while writing these notes.  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.  Record each and every minute you see there is a new patient with behavior issues  Offer other staff to help you recording these notes carefully. e. Communication notes  Communication note are simple notes you are just letting other members of staff know about some information.  Somehow, these notes called “over” locally in Pakistan.  Example: a certain labs has been sent; a patient needs to be ready to be picked up tomorrow morning at 9.00 am  You are just informing other staff of internal tasks.  By writing these notes, you’ll make sure you don’t get in trouble with your staff. f. Death notes  Death notes can be quite simple but also very serious.  Report 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 in-depth and long note.  Don’t omit any details and time records.  Document everything you did, everything you didn’t do and why you didn’t do it.  Get help from supervisor or DON to sit down and write it with you.
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