Nursing notes examples

Nursing notes examples DEFAULT

How To Write a Nursing Progress Note

When caring for patients, medical professionals write nursing progress notes in order to keep a record of their patient's recovery and care. These notes include important information about the patient and serve as a record for the patient's time spent in the hospital's or clinic's care. If you are interested in working in a medical field such as nursing, it is important that you know how to write nursing progress reports. In this article, we describe what a nursing progress note is and provide instructions, examples and tips for how to write your own.

What is a nursing progress note?

Nursing progress notes are the records nurses and doctors keep during a patient's hospitalization. Because nurses often are the professionals who spend the most time with patients, they add special details about the care the patient is receiving and their recovery progress.

These notes help medical professionals keep track of the medications and care a patient received and allows for the patient's medical records to be as up-to-date as possible. In many cases, progress notes also help doctors and nurses create updated care plans as their patient's condition changes.

Related:10 Nursing Fields To Consider for Your Career

Elements to include in a nursing progress note

When writing nursing progress notes, it is best to include as much detail as possible. This helps provide accurate and helpful context to the other care providers. Here's a list of some elements to consider including in your nursing progress note:

  • Date and time of the report
  • Patient's name
  • Doctor and nurse's name
  • General description of the patient
  • Reason for the visit
  • Vital signs and initial health assessment
  • Results of any tests or bloodwork
  • Diagnosis and care plan
  • Patient's response to care
  • Instructions for further care
  • Additional observations

Related:Becoming a Patient Liaison (With Steps)

How to write a nursing progress note

Many medical professionals use the SOAPI method when writing nursing progress notes. SOAPI stands for subjective, objective, assessment, plan and interventions. Here's a list of steps to follow in order to write a nursing progress note using the SOAPI method:

1. Gather subjective evidence

After you record the date, time and both you and your patient's name, begin your nursing progress note by requesting information from the patient. This information is likely subjective and limited to the patient's knowledge and perspective. Subjective evidence includes the patient's pain level, the reason for their visit and concerns they have. When appropriate, consider asking any family member or friend accompanying your patient if they have noticed anything about the patient's health.

Try to act with empathy and use your active listening skills to note your patient's concerns and show them you are invested in their care.

Related:How To Improve Your Listening Skills

2. Record objective information

After speaking with the patient and listening to their perspective, gather objective data to include in your progress note. This includes information such as the patient's vitals, observable symptoms and the results of any tests of bloodwork you or the doctor ordered. Objective information often supports the subjective information the patient provides, helps provide a context for the patient's concerns and leads to a diagnosis for the patient.

3. Record your assessment

In this section, record notes about the patient's condition based on the conclusions you and the primary care physician draw from the patient's symptoms and objective data. Your assessment also includes any medication the doctor prescribed to the patient and the patient's response. Try to notice any changes in the patient's appearance, attitude and symptoms from when they their admission began.

4. Detail a care plan

The care plan section of your nursing progress note includes any course of action you and the doctor plan to take for the benefit of the patient. For example, if the patient has an upcoming MRI scan, you could mention it in the progress note. It is also important to detail any relevant information regarding the patient's reaction to the care plan. For example, if you and the doctor recommend the patient return for a check-up appointment and they refuse, write this in the progress note.

5. Include your interventions

The interventions section of your nursing progress note can include a variety of information. Mostly, this section of your progress note details any additional facts about the care the patient received during your shift. Try to include details about the times you administered medication to the patient, any requests they had and other observations you make about the patient.

Related:Observation Skills: Definition and Examples

Nursing progress note example

When practicing for writing nursing progress notes, it may be helpful for you to consider an example of one. This is what a nursing progress note may report:

Date: 11/04/2021

Time: 5:36 pm

Patient name: Avery Kane

Nurse on duty: Mary Ann Merjos

Avery Kane is a 24-year-old female suffering from severe abdominal pain. The patient is alert and requesting pain medication. Miss Kane indicates her pain level to be at a seven. Her brother, who brought her in, informed us that Miss Kane has been nauseous and refused to eat anything earlier that day. The stomach pain is most severe on her right side and Miss Kane described it as a sudden pain upon her admittance.

Miss Kane's BP is 110/70, her pulse is 105 and her temperature is 101F. She has diminished breath sounds and significant pain and tenderness in the lower right quadrant of her abdomen.

After consulting with the attending physician, we conclude that Miss Kane is suffering from appendicitis and needs immediate surgery for removal. The patient is compliant and receptive to this diagnosis.

The surgeons plan on using dissolvable stitches so Miss Kane will not need to return to get them removed. In her outpatient care, we recommend she wears loose-fitting clothes and refrains from strenuous activities. We will check-in by phone as the patient recovers from home.

We expect to discharge Miss Kane tomorrow morning.

Tips for writing a nursing progress note

Here are some tips for you to consider when writing your own nursing progress notes:

Ask for directions

While many nurses and doctors use the SOPAI method to write nursing progress notes, some hospitals and clinics may have their own templates or routines for nursing progress notes. When starting at a new workplace, be sure to ask how your supervisor expect you to write and organize your progress notes.

Be objective

It is important to be objective as possible when writing your progress notes. Try to only include facts and observations. This helps to keep your progress reports accurate and accessible to all who may need to reference them.

Add details later

Many nurses and doctors record an outline of information while speaking with the patient and then go back to add details to the progress note after the consultation. Finishing your notes for one patient before seeing another is important because it can help you remember more details about your visit. In situations where you cannot finish your notes before seeing another patient, try to at least write down the most important details.

Be concise

While it is beneficial to have thorough notes, try to keep them concise as well. To keep your reports concise, only include relevant details in the progress note and try to be descriptive in a few words. This allows other medical professionals to review your progress note quickly. It also decreases the amount of time you spend taking notes.

Write end-of-day summaries

For some patients, it may be necessary to add an end-of-day summary about the care the recieve and other details. This helps professionals who are working the next shift keep track of your patient's progress. End-of-day summaries also give you the chance to review your notes for the day and address any changes that need to be made to your nursing progress notes.

Read other nursing progress notes

Most medical professionals adopt their own voice and style for writing nursing progress notes. After learning the format that your supervisor prefers, consider reading other professionals' notes to compare your style to theirs. In some cases, it may inspire you to use better practices when writing your own notes. This beneficial learning method also helps you become more familiar with nursing progress notes.

Sours: https://www.indeed.com/career-advice/career-development/nursing-progress-note-example
SOAPI Note

You may have heard the adage in nursing school or from a co-worker:  As a nurse, “if you didn’t chart it, it didn’t happen!”  Charting takes up a large portion of your shift, especially if you are doing it correctly. While time-consuming, good charting is essential to providing top-notch patient care. Not only does charting provide nurses and doctors caring for a patient on future shifts an accurate picture of what happened on previous shifts, but it also becomes a permanent part of the patient’s medical record. It can even be used for legal purposes.

Some organizations have certain requirements for how charting must occur. Most hospitals have gone to a computerized documentation system, but you may occasionally come across an institution that still does things with pen and paper. Regardless, writing a good note at the end of your shift is essential for every patient.

There are several different ways to write a nursing note, but this article will focus on one of the most popular and how it is written: the SOAPI note. This article will break the SOAPI note down so you can decide if it’s a format that will work for you. As always, be sure to check with your organization to determine how they want their notes written.

SOAPI Note


The term “SOAPI” is actually an abbreviation of the parts of the note. These are Subjective, Objective, Assessment, Plan, and Interventions.

Subjective

Subjective refers to things the patient can tell you and often includes pain level and feelings or concerns. It can also refer to things a patient’s family members tell you.

Objective

Objective refers to hard data you collect regarding the patient. This can include vital signs, laboratory results, observable signs and symptoms, and your physical assessment findings.

Assessment

Assessment refers to your overall interpretation of the subjective and assessment. Is the patient improved since admission? Are there new issues that you are observing that need to be addressed? All of these things belong in the assessment.

Plan

The plan refers to the patient’s plan of care. How is the medical team addressing the patient’s health problems? Are there upcoming tests or blood draws? Is the patient on medications to treat a problem that you are monitoring response to? These are examples that fall under the plan.

Interventions

Interventions refer to the things we are doing for the patient. Examples of intervention can include treatments and medications and education provided to the patient on your shift.

Below is an example of a SOAPI note:

“S –

Mr. Smith is an 88-year-old male with a diagnosis of congestive heart failure. The patient is alert and oriented x 1 but pleasantly confused. He complained of shortness of breath on this shift and stated the 2 liters of oxygen made him feel better. He verbally denied pain and his nonverbal pain score was 0. His daughter visited today and advised that he was trying to climb out of bed to go to the bathroom because of his confusion. She stated he “forgot he was in the hospital.”

O –

Today, the patient’s vital signs were as follows: BP 162/82, Pulse 64 and regular, Respirations 20 per minute, and pulse ox 98% on 2L Oxygen via nasal cannula. His lungs are diminished with scattered crackles. Bowel sounds are active, and the patient had a bowel movement x 2 today, both soft. Incontinent of urine and wearing a diaper. Skin intact at this time. Skin color is pale. 2+ non-pitting edema noted in bilateral calves and ankles. BNP was greater than 20,000 today.

A –

The patient’s status is improving, and he is less short of breath than in previous days. He continues with edema. Currently, the patient is at risk for falls due to confusion and will need fall precautions enforced.

P –

Initiate fall precautions with a bed alarm/body alarm. Continue with Lasix for diuresis. Awaiting cardiology consult tomorrow. Pt had an echocardiogram today, and the results are pending.

I –

Assessed patient and reconciled medications. Spoke with daughter, pt’s power of attorney, to provide update and education on patient’s condition. Laboratory obtained morning labs without a problem, and vascular therapy placed a new 18g peripheral IV as the previous one was due for a change. Pt took all morning meds without a problem. Reoriented patient and provided opportunities for toileting and for making needs known every 1-2 hours today to lessen the risk of fall.”

With a good quality nursing note, such as a SOAPI note, nurses can make it crystal clear exactly what is going on with a patient’s care. Nursing notes are a crucial part of the patient’s medical record and provide all the information future caregivers will need to provide continuous care for patients in the healthcare setting. They are also the perfect way to wrap up your shift with confidence and ease.

If you are a new traveler or looking into becoming a Travel Nurse:

START HERE

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Sours: https://www.thegypsynurse.com/blog/charting-made-easy-soapi-note/
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How to Write Great Nurses’ Notes

Lower half of African-American man wearing blue scrubs and a stethoscope scrolling through a document on a tablet.

Nurses learn early and often that patient care is the No. 1 priority — but charting is a close second. Balancing charting and meeting your patient’s needs can be tough but is a necessity to accurately relay all updates to various providers. In fact, according to Science Direct, interdisciplinary communication is required for high-quality care, and improving communication will ultimately help improve patient outcomes.

Think about it this way: A nurse, doctor, or any other healthcare professional coming on shift is only as good as the charting they have on the patient. Nurses’ notes are an integral part of this chart, so they should be accurate, up to date, and concise. But how much detail is too much detail? And how can you balance patient interaction with writing accurate nurses notes? You’re going to do a lot of charting and notating in your nursing career. These tips will help you make these assessments thorough, helpful, and less stressful.


What Are Nurses’ Notes?

Since nurses are patient advocates and often have the most contact with their patients, their notes provide the most complete picture of the patient’s health to the other health professionals and specialists involved in their care. These notes are the formal documentation that nurses make when charting, based on the notations and scribbles nurses gather during a patient visit. They may also incorporate charting by exception, a shorthand way of noting the “exceptions” or abnormalities the patient is experiencing by initialing lists and charts.

Keeping thorough and accurate notes is extremely important for maintaining effective communication between nurses and the medical staff, but if a malpractice case is ever filed, these charts will be used by the legal team involved. Considering that nurses care for a number of patients at a time, the formal notes taken on a patient will help a nurse remember the events of the day, the care provided, and the specialists involved if she’s ever sued or called as a witness.

What’s the Difference Between Nurses’ Notes and Charting?

Nurses’ notes are part of charting. They are short-form notations on pre-established lists (charting by exception), often with a one-paragraph summary that gives a picture of the patient’s health during the visit or time period.

What Are Some Examples of Nurses’ Notes?

Here are some examples of good nurses' notes to give you a little more context:

  • “When I walked in the room, the patient was blue and having trouble breathing. I called a Code Blue and started CPR. Then Code team arrived.”

  • “Lung sounds clear to auscultation bilaterally. Color pink. No signs of respiratory distress noted. VSS. Patient eating 90% of his meals and tolerating well. No abdominal distention or emesis this shift. Patient ambulating adequately. Voiding spontaneously. No BM this shift. Patient’s weight remained the same. Spouse visited patient today. Bed rails up x4. No hazards in room. Call light within reach.”

When nurses talk about charting, they are usually talking about the computer chart. Because many hospitals and clinics are going paperless, the physical (clipboard) chart may only have the patient’s history in it, while the computer chart has everything that happened during this stay.

When Should Nurses Chart Their Notes?

Ideally, you make quick notations during your visit and add more depth immediately after you leave the patient’s room, when the information is fresh and top-of-mind. American Nurse Today says making brief notes while assessing the patient will help you chart faster and give more accurate (formal) nurses’ notes right after your visit. This helps you move efficiently between each patient you need to see. Visit, chart, repeat.

What Should Be Included in Nurses’ Notes?

The three thoughts to keep in mind when you’re writing these notes are:

  1. Will this help all other staff members working with this patient?
  2. Did this summarize the patient’s current experience?
  3. Would this help remind me of the patient’s condition and care five years from now if I ever need to testify on this case?

Because your notes are so important, Tricia Chavez, RN, educator from Redlands Community Hospital in Redlands, California, suggests you include:

  • Date/Time
  • Patient’s Name
  • Nurse’s Name
  • Reason for Visit
  • Appearance
  • Vital Signs
  • Assessment of Patient
  • Labs & Diagnostics Ordered
  • Evaluation of How Medical Interventions Worked
  • Instructions/Education
  • Family Interactions
  • Recommendations & Observations
  • Anything Out of the Ordinary

What Should Not Be Included in Nurses' Notes?

Lippincott Nursing Center states you should only include the facts, rather than your personal opinion. However, your opinion can be verbalized to other healthcare professionals so they can get a better picture of the patient (e.g., Social Services notified; request for one more day of stay due to patient unable to care for self at home).

Here are some other notations that cross an ethical line when put in formal/permanent notes:

1. Personal Information Regarding the Patients' Family Members & Friends*

While it’s OK to give very generalized information on them (e.g., they visited), nothing personal should be included (e.g., they were intoxicated, unkempt, uncaring, etc.).

2. Dialogues You’ve Had About Patients Between Providers*

Instead of conversation details, just note that you’ve informed certain physicians.

3. Anything From the ISMP List of Abbreviations*

These are often misinterpreted and lead to medication errors.

4. Your Opinion*

Instead, report on your recommendations and the systems you have put in place or staff you’ve notified (e.g., this RN recommends social worker evaluate patient’s ability to obtain supplies needed at home upon discharge).

5. Negativity About Staff That Could Be Portrayed as Defamatory*

There should be another system for reporting staff issues within your organization. But there are ways around saying what you want to say. For example:

  • You want to say: “The doctor isn’t concerned about something that I’m concerned about.”

  • But actually say: “MD notified. No further orders.”

  • You want to say: “I’m concerned the patient’s grandmother is abusive to patient.”

  • But actually say: “Please evaluate grandmother for care after discharge” in Social Services order. Then, speak freely when Social Services talks to you in person.

As an aside, you should never chart after your shift. If, for whatever reason, off-duty charting is needed and/or necessary, you should comply with your employer’s instructions or seek guidance from your supervisor on how to handle the situation.

11 Tips for Writing Excellent Nurses’ Notes — From a Nurse

As a nurse since 2001 and mentor at my hospital, here is the advice I give to new nurses:

Tip #1: Be concise.

Instead of a long-winded note, just add pertinent facts and keep it short.

Tip #2: State the facts.

Chart what you see, hear, and do.

Tip #3: Read other nurses’ notes.

Everyone will have their own voice. But you’ll see how veteran nurses balance their facts with their insight.

Tip #4: Find a mentor.

Look for an experienced nurse who you trust to give you constructive feedback on your notes.

Tip #5: Write shorthand.

Keep shorthand notes while talking. Keep eye contact while writing shorthand keywords for your post-visit write-up. Then chart it as soon as you can after. For example, if your patient is describing sharp stomach pains, you might write "9/10 pain/LLQ."

Tip #6: Chart after each visit.

Take five minutes to chart and write thorough nurses’ notes right away; that way, it's fresh in your mind.

Tip #7: Summarize.

In the hospital setting, write an end-of-the-day note in each patient's’ chart, starting in the morning and go through the entire day. A good summary is helpful to everyone involved with the patient. In the clinic setting, there should be a summary in each patient's’ chart with every visit.

Tip #8: Note responses.

Express how the patient responded to treatment. Chart whether they adhered to advice given by you and the doctor.

Tip #9: Describe observations.

Write down all pertinent observations with the patient. For example, “color pink, swelling to lower extremities, pain 4/10.”

Tip #10: Never speculate.

We always want to write how we feel the patient feels, but this isn't usually accurate. Instead, chart what the patient is literally saying.

Tip #11: Use your resources.

Know that you have resources around you. Use the nurses who have been around for a long time; their experience is invaluable. There are usually charge nurses or nurse managers you can utilize. It’s always better to ask for help than to not chart enough information.


Image courtesy of iStock.com/Hiraman


The views expressed in this article are those of the author and do not necessarily reflect those of Berxi™ or Berkshire Hathaway Specialty Insurance Company. This article (subject to change without notice) is for informational purposes only, and does not constitute professional advice.

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Jennifer Tomaselli, RN, MSN, RNC
Jennifer Tomaselli, RN, MSN, RNC

is a contributing writer for Berxi. She has a nursing degree and works in Labor and Delivery and NICU. Jennifer is a freelance writer and editor specializing in nursing, healthcare, and fitness. She enjoys living in southern California with her husband and teenage son.

Sours: https://www.berxi.com/resources/articles/nurses-notes/
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