Learning how to write a nursing note is totally a thing. And it's one of those things they don't go over in nursing school... insert me.. so glad you're here. 

This is something you will eventually learn with time on your unit.. but who has time for that... amirite? I would like to save you the embarrassment and uncertainty and just tell you what you should never do...as well as some examples of what to say and how to say it.

Tip #1

Don't Throw Physicians Under The Bus In Your Note

Everyone will read this note. Everyone. I am only talking about nursing notes that go in the patients chart/file, I am not talking about emergency situations where you as the nurse need to escalate a situation for the safety of a patient. 

No matter what is said over the phone or in conversation, if it is something you would prefer the patient, family and administration not to hear, then be mindful of how you choose to write your note. And keep in mind that we are all on the same team and we all share the common goal of helping our patients.

We are all human. And hospitals get busy and can be challenging. Everyone is trying to do the best they can. Sometime things may take longer than you like. Like an order being placed for a patient at 2am. The patient should always come first.

That being said, leave your feelings out of a nursing note. Only the facts should be written.  It doesn't matter how you feel about a physician or patient or any history involving either. A note should spew the facts, and the facts only. If it has more than just the facts you run the risk of looking unprofessional.

For example: If you ask the physician for a colace order (stool softener) because the patient is complaining of constipation at 3am and they say they are too busy and don't have time to write it just yet (btw, a colace order can wait till 8am when normal people are awake...more on this when you click to read the rest) Do NOT say, "I asked MD for order, MD said they are too busy to write order and will get around to it." 

Instead say, "Patient complaining of constipation, MD aware, order to be placed." You are being professional, you are making it known that you have spoken with the physician, and that they are aware, while not jumping up and down screaming that this patient should have had the order placed already..... get my drift?

Tip #2

Check your spelling

Like I have mentioned above, everyone reads these notes. Don't make yourself look bad by having misspelled words or writing in text short hand words like "ur" and "thnx". It is acceptable to use medical terminology like c/o (complaining of) VSS (vital sign stable) and s/p (status post) to name a few.

This documentation is permanent and you never know when it will be read and re-read. Your notes may be used months or years later in a deposition (talking from experience here and boy am I glad my notes and documentation were spot on) so make sure you have not left anything out and that they paint a picture of truth.

Tip #3

CYA (cover your A$$)

If you didn't document it, it DIDN'T HAPPEN! I can't stress this enough. It doesn't matter if you say, "Oh I promise I gave that labetalol, I didn't scan it or document the BP of 174/105 but I really did give the blood pressure med. I don't know why the patient seized or had a stroke...patient was fine when I was there.

Nope, won't fly. You just made yourself look negligent and dangerous. And you may find yourself in court and with out a job. Yes, sounds scary, but it's true. Whatever you do, document it! Even when you're tired and find yourself ready to face plant on your keyboard while ready to insert a note about Kid Rock (yes thats happened to me) pull it together, get a coffee, take a lap and sit back down and write that detailed note. 

A phrase you should get used to adding to your notes when it applies is this:

Patient stable, will continue to monitor.

Patient told to call md with any (insert sign and symptoms of issue here). Patient and spouse verbalize understanding.

This is super important because it lets people know you have instructed them of the signs and symptoms to look for as well as to call the physician if they experience any. You are also making it aware that they have verbalized that they understand what you have said. 

OB note Ex:

34 yr old G2P0 at 32 weeks gestation c/o lower back pain. MD bedside assessing patient. Vaginal exam performed, no cervical dilation noted. Category I tracing, patient reports good fetal movement and denies contraction pain.  Pt discharged to home. Pt instructed to call MD with any vaginal bleeding, decreased fetal movement, leaking of fluid or painful contractions. Patient verbalize understanding. 

Always remember that you are signing your name to this chart. Its basically a tattoo! So make sure what you are writing is accurate and was completed by you.

xx

Jessie

P.s. Want more tips like this? Join the JOD SQUAD for Nurses and Nursing Students- membership doors are OPEN! Click here to join!

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