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.
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 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.
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.
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.
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.
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.
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.
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.
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.
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.
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
Here are some tips to keep in mind to help you write a useful nursing note example of your own.
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.
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.
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.
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.
