Examples Of Nursing Notes In Charts

Nursing notes are the backbone of patient care, serving as a detailed record of a patient's journey through the healthcare system. They provide a chronological account of a patient's health status, the care provided, and the patient's response to treatment. Accurate and comprehensive nursing notes are essential for effective communication among healthcare professionals, ensuring continuity of care and patient safety. This article delves into various examples of nursing notes in charts, highlighting their importance, components, and best practices for documentation.

The Importance of Nursing Notes

Nursing notes are more than just a record; they are a legal document that reflects the quality of care provided. They serve multiple critical functions:

• Communication: Nursing notes facilitate communication between nurses, physicians, and other healthcare team members.
• Continuity of Care: They ensure that each caregiver is aware of the patient's current status, previous treatments, and responses.
• Legal Protection: Accurate and thorough documentation can protect healthcare providers in the event of legal challenges.
• Quality Improvement: Nursing notes provide data for quality improvement initiatives, helping to identify trends and areas for improvement in patient care.
• Reimbursement: Detailed notes support billing and reimbursement processes by justifying the services provided.
• Research and Education: Nursing notes can be used for research and educational purposes, contributing to the advancement of nursing practice.

Key Components of Nursing Notes

A well-written nursing note typically includes the following components:

• Date and Time: Each entry must be dated and timed accurately.
• Patient Identification: The patient's name and identification number should be included.
• Objective Data: Factual, measurable information such as vital signs, lab results, and physical assessment findings.
• Subjective Data: The patient's own words and descriptions of their symptoms and feelings.
• Nursing Interventions: Specific actions taken by the nurse, such as medication administration, wound care, and patient education.
• Patient Response: How the patient responded to the nursing interventions.
• Plan of Care: Any changes or updates to the patient's care plan.
• Signature and Credentials: The nurse's signature and professional credentials (e.g., RN, LPN).

Common Charting Methods

Several charting methods are used in nursing documentation, each with its own structure and focus:

• Narrative Charting: Traditional method of writing notes in a descriptive, story-like format.
• SOAP/SOAPIE Charting: A problem-oriented approach that organizes notes into Subjective, Objective, Assessment, and Plan (SOAP), with optional Implementation and Evaluation (SOAPIE) components.
• PIE Charting: Focuses on identifying Problems, Interventions, and Evaluation of nursing care.
• Focus Charting (DAR): Centers on a specific concern or focus, documenting Data, Action, and Response.
• Charting by Exception: Only documenting abnormal or significant findings, with the assumption that all standards of care are met unless otherwise noted.

Examples of Nursing Notes in Charts

1. Admission Note

An admission note is created when a patient is first admitted to a healthcare facility. It provides a baseline assessment of the patient's condition.

Example:

Date: 2024-01-27 Time: 08:00 Patient: Jane Doe, ID: 1234567

Subjective: Patient states, "I have been feeling short of breath for the past few days and have a cough." Reports a history of hypertension and asthma.

Objective:

• Vital Signs: BP 160/90 mmHg, HR 100 bpm, RR 24, Temp 98.6°F, SpO2 92% on room air.
• Alert and oriented to person, place, and time.
• Audible wheezing in both lungs.
• Skin warm, dry, and intact.

Assessment: Patient admitted with shortness of breath and possible exacerbation of asthma.

Plan:

• Administer oxygen via nasal cannula at 2 L/min.
• Obtain chest X-ray and EKG as ordered.
• Administer albuterol nebulizer treatment as ordered.
• Monitor vital signs and respiratory status every 15 minutes.
• Notify physician of any changes in condition.

Signature: John Smith, RN

2. Medication Administration Note

This type of note documents the administration of medications, including the drug name, dosage, route, time, and patient response.

Example:

Date: 2024-01-27 Time: 09:00 Patient: Jane Doe, ID: 1234567

Medication: Albuterol 2.5 mg via nebulizer.

Route: Inhalation

Reason: Wheezing and shortness of breath.

Patient Response:

• Patient tolerated treatment well.
• After 20 minutes, patient reports decreased shortness of breath.
• Repeat vital signs: BP 150/80 mmHg, HR 90 bpm, RR 20, SpO2 95% on 2 L/min O2.
• Lung sounds improved, with decreased wheezing.

Signature: John Smith, RN

3. Pain Management Note

Pain management notes document the patient's pain level, interventions used to manage pain, and the patient's response to those interventions.

Example:

Date: 2024-01-27 Time: 10:00 Patient: Jane Doe, ID: 1234567

Subjective: Patient reports pain level of 6/10 in her chest, described as a sharp, stabbing pain.

Objective:

• Patient grimacing and guarding chest.
• Vital signs: BP 155/85 mmHg, HR 95 bpm, RR 22.

Intervention:

• Administered morphine 2 mg IV per physician order for pain.
• Provided comfort measures, including repositioning and relaxation techniques.

Patient Response:

• 30 minutes post-medication, patient reports pain level decreased to 3/10.
• Patient resting comfortably.

Signature: John Smith, RN

4. Wound Care Note

Wound care notes document the assessment and treatment of wounds, including the wound's appearance, size, drainage, and any interventions performed.

Example:

Date: 2024-01-27 Time: 11:00 Patient: John Smith, ID: 9876543

Wound Location: Sacral pressure ulcer.

Assessment:

• Wound measures 4 cm x 3 cm x 1 cm.
• Wound bed is red and moist, with minimal serous drainage.
• Periwound skin is intact, with slight redness.

Intervention:

• Wound cleansed with normal saline.
• Silver alginate dressing applied.
• Patient repositioned to offload pressure on the sacrum.

Plan:

• Continue wound care daily.
• Monitor for signs of infection.
• Consult wound care specialist if no improvement noted.

Signature: Jane Doe, RN

5. Neurological Assessment Note

This note documents the patient's neurological status, including level of consciousness, orientation, motor function, and sensory function.

Example:

Date: 2024-01-27 Time: 12:00 Patient: Michael Brown, ID: 4567890

Assessment:

• Alert and oriented to person, place, and time.
• GCS score of 15 (Eyes 4, Verbal 5, Motor 6).
• PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation).
• Motor strength 5/5 in all extremities.
• Sensation intact to light touch in all extremities.
• No facial droop or slurred speech noted.

Plan:

• Continue to monitor neurological status every 4 hours.
• Report any changes to physician immediately.

Signature: Emily White, RN

6. Fall Risk Assessment Note

Fall risk assessment notes document the assessment of a patient's risk for falls and any interventions implemented to prevent falls.

Example:

Date: 2024-01-27 Time: 13:00 Patient: Mary Johnson, ID: 6543210

Assessment:

• Morse Fall Scale score: 45 (Moderate Risk).
• History of falls in the past 6 months.
• Uses a cane for ambulation.
• Impaired vision.
• Patient reports feeling unsteady when walking.

Interventions:

• Patient educated on fall prevention strategies.
• Call light placed within reach.
• Bed in low position.
• Non-slip socks provided.
• Assisted with ambulation.

Plan:

• Reassess fall risk daily.
• Ensure assistive devices are readily available.
• Provide a safe environment.

Signature: David Green, RN

7. Patient Education Note

Patient education notes document the information provided to the patient and their understanding of that information.

Example:

Date: 2024-01-27 Time: 14:00 Patient: Robert Wilson, ID: 3216540

Education Topic: Diabetes management.

Content Covered:

• Importance of blood glucose monitoring.
• Proper technique for insulin administration.
• Dietary recommendations for diabetes.
• Signs and symptoms of hypoglycemia and hyperglycemia.
• Importance of regular exercise.

Patient Response:

• Patient verbalized understanding of the information provided.
• Patient demonstrated proper technique for insulin administration.
• Patient expressed commitment to following dietary recommendations.

Plan:

• Continue to reinforce education as needed.
• Provide written materials for reference.
• Schedule follow-up appointment with diabetes educator.

Signature: Susan Brown, RN

8. Discharge Note

A discharge note summarizes the patient's hospital stay, including the reason for admission, treatments received, and discharge instructions.

Example:

Date: 2024-01-27 Time: 15:00 Patient: Jane Doe, ID: 1234567

Reason for Admission: Shortness of breath and exacerbation of asthma.

Treatment Summary:

• Administered oxygen therapy.
• Administered albuterol nebulizer treatments.
• Administered corticosteroids.
• Patient responded well to treatment.

Discharge Instructions:

• Continue albuterol inhaler every 4-6 hours as needed for wheezing.
• Continue oral prednisone as prescribed.
• Follow up with primary care physician in 1 week.
• Educated on signs and symptoms of respiratory distress and when to seek emergency care.

Medications:

• Albuterol inhaler: 2 puffs every 4-6 hours PRN.
• Prednisone 20 mg: Take 1 tablet daily for 5 days.

Signature: John Smith, RN

9. Telephone Order Note

This note documents any orders received from a physician via telephone.

Example:

Date: 2024-01-27 Time: 16:00 Patient: Michael Brown, ID: 4567890

Order Received From: Dr. Smith

Order: Increase IV fluid rate to 125 mL/hr.

Reason: Patient exhibiting signs of dehydration.

Read Back and Verified: Order read back to Dr. Smith and verified.

Signature: Emily White, RN

10. Incident Report Note

An incident report note documents any unusual occurrences or incidents that occur during patient care.

Example:

Date: 2024-01-27 Time: 17:00 Patient: Mary Johnson, ID: 6543210

Incident: Patient found on the floor next to her bed.

Description:

• Patient stated she attempted to get out of bed to use the restroom and fell.
• No apparent injuries noted.
• Vital signs stable: BP 130/80 mmHg, HR 80 bpm, RR 18.

Actions Taken:

• Patient assisted back to bed.
• Physician notified.
• Neurological assessment performed, no changes noted.
• Incident report completed.

Signature: David Green, RN

11. Code Blue Documentation

During a code blue event (cardiac or respiratory arrest), meticulous documentation is critical to track interventions and patient response.

Example:

Date: 2024-01-27 Time: 18:00 Patient: Robert Wilson, ID: 3216540

Event: Patient found unresponsive in bed, no pulse, no respirations.

Initial Actions:

• Code Blue initiated.
• CPR started immediately.
• Oxygen administered via bag-valve-mask.

Interventions:

• Epinephrine 1 mg IV administered at 18:02.
• Epinephrine 1 mg IV administered at 18:05.
• Amidarone 300 mg IV administered at 18:08.
• Defibrillation performed at 200 joules at 18:10.

Patient Response:

• Return of spontaneous circulation (ROSC) achieved at 18:12.
• Pulse 60 bpm, BP 90/60 mmHg, RR 12.

Post-Resuscitation:

• Patient intubated and placed on mechanical ventilation.
• Transferred to ICU.

Signature: Susan Brown, RN (Code Team)

12. Pediatric Nursing Note

Pediatric nursing notes require specific attention to developmental stages and age-appropriate assessments.

Example:

Date: 2024-01-27 Time: 19:00 Patient: Lily Adams, ID: 7890123 (Age 3 years)

Subjective: Mother states, "Lily has had a fever and runny nose for the past 2 days. She is also refusing to eat."

Objective:

• Vital Signs: Temp 102.5°F, HR 120 bpm, RR 28, SpO2 98% on room air.
• Alert but irritable.
• Nasal congestion and mild cough.
• Tympanic membranes clear bilaterally.

Assessment:

• Possible upper respiratory infection.

Interventions:

• Administered acetaminophen 160 mg PO for fever.
• Provided cool compress to forehead.
• Encouraged oral fluids.

Plan:

• Monitor temperature every 4 hours.
• Continue to encourage oral fluids.
• Notify physician if fever persists or condition worsens.

Signature: Jennifer Lee, RN

13. Geriatric Nursing Note

Geriatric nursing notes should address age-related changes, comorbidities, and functional status.

Example:

Date: 2024-01-27 Time: 20:00 Patient: George Taylor, ID: 8901234 (Age 85 years)

Subjective: Patient states, "I've been feeling weaker than usual and having trouble sleeping."

Objective:

• Vital Signs: BP 140/80 mmHg, HR 70 bpm, RR 16, Temp 97.5°F.
• Patient appears frail and moves slowly.
• Reports nocturia twice per night.
• Mini-Mental State Exam (MMSE) score: 26/30.

Assessment:

• Possible decline in functional status.

Interventions:

• Assisted with ambulation to the restroom.
• Provided a light snack and warm milk before bedtime.
• Educated on strategies to improve sleep hygiene.

Plan:

• Monitor functional status and cognitive function.
• Consult with occupational therapy for mobility assessment.
• Ensure a safe environment to prevent falls.

Signature: Brian Clark, RN

14. Mental Health Nursing Note

Mental health nursing notes document the patient's emotional state, behavior, and response to therapeutic interventions.

Example:

Date: 2024-01-27 Time: 21:00 Patient: Sarah Miller, ID: 9012345

Subjective: Patient states, "I'm feeling very anxious and overwhelmed. I can't seem to calm down."

Objective:

• Patient appears restless and agitated.
• Pacing and wringing hands.
• Speech is rapid and pressured.
• Affect is anxious and tearful.

Interventions:

• Provided a calm and supportive environment.
• Encouraged patient to express her feelings.
• Assisted patient with relaxation techniques, including deep breathing.
• Administered lorazepam 1 mg PO per physician order for anxiety.

Patient Response:

• 30 minutes post-medication, patient reports feeling slightly calmer.
• Resting quietly in her room.

Signature: Linda Davis, RN

15. Home Health Nursing Note

Home health nursing notes document the patient's condition, care provided, and home environment.

Example:

Date: 2024-01-27 Time: 10:00 Patient: Thomas Evans, ID: 0123456

Visit Reason: Routine follow-up for wound care.

Subjective: Patient states, "My leg has been feeling better since you started coming. The pain is less, and it seems to be healing."

Objective:

• Wound Location: Lower left leg ulcer.
• Assessment: Wound measures 3 cm x 2 cm x 0.5 cm. Wound bed is pink and granulating. No signs of infection.
• Home Environment: Clean and safe. Patient has good support system.

Interventions:

• Wound cleansed with normal saline.
• Applied hydrocolloid dressing.
• Educated patient on proper wound care techniques and signs of infection.

Plan:

• Continue wound care three times per week.
• Monitor for signs of infection.
• Contact physician if any concerns arise.

Signature: Carol White, RN

Best Practices for Writing Nursing Notes

• Be Accurate: Ensure all information is factual and based on objective data whenever possible.
• Be Concise: Use clear and concise language. Avoid unnecessary jargon.
• Be Objective: Document observations rather than personal opinions or judgments.
• Be Timely: Document events as soon as possible after they occur.
• Be Complete: Include all relevant information about the patient's condition, interventions, and response.
• Be Legible: Ensure that your handwriting is clear and easy to read.
• Use Standard Abbreviations: Only use approved abbreviations to avoid confusion.
• Correct Errors Properly: Draw a single line through the error, write "error," and initial and date the correction.
• Maintain Confidentiality: Protect patient privacy by following HIPAA guidelines.
• Use Quotes: When documenting subjective data, use the patient's own words in quotation marks.
• Follow Facility Policy: Adhere to your healthcare facility's specific policies and procedures for documentation.

The Future of Nursing Documentation

The future of nursing documentation is increasingly digital, with electronic health records (EHRs) becoming the standard. EHRs offer numerous benefits, including improved legibility, accessibility, and data analysis capabilities. As technology advances, expect to see more integration of artificial intelligence (AI) and natural language processing (NLP) to assist with documentation, making it more efficient and accurate.

In conclusion, nursing notes are a vital component of patient care. By understanding the key components of nursing notes, utilizing appropriate charting methods, and following best practices for documentation, nurses can ensure effective communication, continuity of care, and patient safety. The examples provided offer a glimpse into the diverse range of nursing notes used in various clinical settings, highlighting the importance of accurate and comprehensive documentation in nursing practice.