Being clear in your communication and paying careful attention to detail is important in healthcare. As nurses, having nursing notes are more than just paperwork – they help you do your work in providing patient care.
Whether you’re looking to improve your documentation skills or new and want to excel, this one’s for you. Here’s a step-by-step guide to writing practical notes.
By the end of this article, you will have the knowledge and tools to create notes that will help you do your job better.
What are Nursing Notes?
Nursing notes are also called progress notes or charting. These are organized in a way that records a few things for your patients:
- Their health status
- Their care
- Response to care
These notes provide you with two purposes: they communicate consistent care to healthcare providers. Secondly, legal documents show details of your patient’s condition, treatments, and outcomes.
So what do you need to do? Be accurate with your notes. If you make a mistake, correct it instead of hiding it. Also, value your patient’s privacy and don’t forget any vital information.
Moreover, keep your notes objective. Don’t make personal judgments or subjective statements about the patients.
Three Effective Nursing Notes
There are a lot of formats depending on what place you work for. These are the types of notes you need to remember and that you can use:
1. SOAP Notes (Subjective, Objective, Assessment, Plan)
Subjective
Starting at this point, you must write your patient’s complaints and feelings in their exact words. For example, your patient can say, “I have been feeling a punch in my stomach for two days straight now.”
Objective
At this point, you could note down the vital signs, like the patient’s blood pressure, heart rate, and body temperature.
Assessment
At these parts, you note down your patient’s condition. What causes the stomach pain? Chest pain? What were the obvious symptoms?
Plan
Now that we’re done with the assessment, this part of the outline lists that you should continue to care for your patient.
2. DAR Notes (Data, Action, Response)
Data
Document the information you gathered. Let’s say, “Patient’s blood glucose level before lunch: 180 mg/dL.”
Action
After recording the data, what did you do? Administer insulin, maybe? Per what protocol?
Response
How did the patient respond to the action? Also, list it down.
3. PIE Notes (Problem, Intervention, Evaluation)
Problem
You start doing the outline by noting the difficulty your patient is facing.
Intervention
Also, the same as the action you intend to do. Also, list down how you administered medicine or treatment to your patient.
Evaluation
After your intervention, also tell the improvements of your patients. How have they improved ever since?
Making Nursing Notes Effective
Of course, it is essential to take care of your patients. Next to that is keeping your notes as detailed as much as possible. Now, to make an outcome that can impact your patient care, here are some necessary steps:
Step 1: Familiarize the HIPAA Compliance
The Health Insurance Portability and Accountability Act (HIPAA) deals with patient privacy and confidentiality. Creating your notes can improve your healthcare outcomes and nursing practices.
Step 2: Always Record the Date, Time, and Location
Always start by mentioning the date, time, and where your assessment took place. Why is this important? Because it gives you and your fellow healthcare professionals a clear timeline of your patient’s care.
Step 3: Identification of the Patient
To help you become more clear with your patient’s assessment, include the following:
- Patient’s full name
- Date of birth
- Medical record numbers
- Hospital ID bands
Having this vital information helps avoid any mix-ups or errors.
Step 4: Organize Your Information Logically
Arrange your nursing notes in a logical and chronological order. Begin with the patient’s current condition or status. Then, follow it up with any historical information. The three types of nursing notes above can help you do just that.
Step 5: Avoid Jargon and Abbreviations
We know it will make using medical terms and abbreviations much easier, but it can cause confusion.
If you use abbreviations, make them understandable. You can explain those terms not commonly used. Don’t use slang or informal language too.
Other Tips for Effective Documentation
Having good nursing notes isn’t just about the rules. It’s a combination of skill, empathy, and precision. To achieve just this, below are some tips to make you improve.
1. Have Narrative Notes
Narrative notes focus on the whole journey of your patient’s care and condition. Yes, writing will take a bit more time, but they can provide more context.
When doing this, include your patient’s reaction, concerns, or unexpected situations that can help you understand them better.
2. Learn the Difference: Objective and Subjective Language
Knowing the difference between these two languages is crucial.
Objective language keeps things professional so you won’t be biased about their condition. Subjective language, on the other hand, allows you to understand how your patients feel and experience.
Objective language records:
- Vital signs
- Observations
- Facts
Subjective language helps you:
- Describe your patient’s pain
- Know your patient’s emotions
- Record their responses
3. Don’t Delay Your Documentations
Every time you talk with the patient, administer something, or do anything that deals with the patient, list it down right away. Delaying it might cause confusion, mistakes, and worse – missing information.
Regularly update your notes, especially if your patient has conditions that change quickly. No matter how big or small the report is, note it down.
4. Handle Your Mistakes Correctly
Let’s face it. You can make mistakes along the way and learn from them if you don’t cover them up.
Draw a single line through the error you made. Write “error” and sign your name, date, and time.
Doing this makes it become a precise correction. It provides accuracy and is easily understandable. Plus, becoming transparent establishes trust and credibility.
5. Don’t Be Biased
Your nursing notes should stick to the facts, observations, and assessments. Avoid putting in your personal opinions or judgments about the patient.
Be aware of any biases you might have and try hard not to let them influence your documentation. Treat every patient with respect and empathy.
On this note…
As you face every shift and deal with many patients, carry this knowledge and advice to write your nursing notes effectively.
Remember, they’re not just plain notes. They show your commitment, passion for healthcare and pledge to deliver the best in patient care.
