How to Write a Good Nursing Note: Example and Tips
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
- Assessment
- 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 what you’ve shared when you find work that fits you through IntelyCare.