What are nursing notes? Nursing notes are an important part of patient care documentation. It consists of a record of patient condition, treatment, response of treatment and changes over time. Nursing notes consist of accurate communication among healthcare providers which affects the patient’s outcome.
What are the key elements for writing nursing notes?
The key elements that are important to write nursing notes are as follows:
- Date and time.
- Patient information such as name, ID, and other information.
- Objective data such as heart rate, blood pressure.
- Subjective data such as concerns and feelings.
- Treatments and actions during treatment.
- Patient’s response to medications and treatments.
- Follow up actions.
Format for writing Nursing Notes
Several formats are used to structure nursing notes as consistency is important for writing an accurate nursing note. Some commonly used formats are:
- SOAP
- DAR
- PIE
SOAP
- S (Subjective): It includes patient complaints, for example he complains of headache or chest pain which is 7/10.
- O (Objective): Measurable data or document like blood pressure which can be measured by BP device such as 130/90.
- A (Assessment): To assess the patient with the information provided by subjective and objective data. For example, patients experiencing angina.
- P (Plan): Treatments or action taken to control the problem, symptoms, or diseases. For example, administering medications for angina or monitoring vitals.
SOAP Nursing Note Example
Here is an example of nursing notes using the format of SOAP.
Date: 10/07/2024
Time: 10: 30 am
Patient Name: Ross Geller
S (Subjective Data): Pain in stomach and vomiting. Rating pain 6/10.
O (Objective Data): Fever 101°F.
A (Assessment): possible gastrointestinal or stomach virus.
P (Plan): Give fluids, medication for nausea and ibuprofen.
DAR
- D (Data): Patient giving information about the situation.
- A (Action): Action taken for the patient.
- R(Response): The response of the patient after the action was taken.
DAR Nursing Note Example:
Date: 19/08/2024
Time: 11:30 am
Patient Name: Chandler Bing
D(Data): Patient is feeling nausea after IV is inserted to administer antibiotics.
A(Action): IV fluid is slowed down, the head of bed is elevated, antiemetic is given to the patient.
R(Response): The patient is feeling fine with no nausea after the above action was taken.
PIE
- P(Problem): What is the problem or issue?
- I (Intervention): What action was taken to address the problem or issue?
- E(Evaluation): What was the result of action taken or evaluation?
PIE Nursing Note Example:
Date: 12/06/2024
Time: 12:30 pm
Patient Name: Joey Tribbiani
P(Problem): Patient complain about the pain where the IV is inserted.
I(Intervention): The IV is removed and reinserted in the other arm.
E(Evaluation): The patient feels no pain this time.
Tips for writing effective Nursing Notes
It is important for nurses to write a perfect nursing note as it can help with effective patient care. Tips to write clear concise nursing documentation are as follows:
- Be accurate and include all details such as time, intervention, response to medication, patient condition including vital signs.
- Make sure to write it down on time so that there is no chance of missing the details.
- Keep professional tone while writing nursing notes.
- Never alter or erase if you make any mistake, instead make a strike through, and write the correct information.
- Avoid any assumptions.
- Sign your full name with designation such as Monica Parker, RN.
- Use standard abbreviations and terminology which is widely accepted in the facility to avoid confusion or miscommunication.
- Utilize technology such as HER or EMR systems and make yourself familiar with the system.
- Use shorter sentences and be specific.
- Use bullet points when it is possible as it is easy and quick to read.
- Protect patient’s privacy.
Importance and Purpose of Nursing Notes
Nursing notes are important to understand the patient’s conditions and help the health workers to provide effective patient care. The importance and purpose of nursing documentation are as follows:
- It is a way of communication between the healthcare providers to keep track of patient conditions.
- These are also considered legal documents, which are crucial during any kind of dispute.
- These records or documentation of the patient’s health keep the new healthcare provider updated f the patient’s condition.
- They are also used for reviewing patient care.
Another Nursing Note example
Here is another Nursing note example.
Date: 10/05/2024
Time: 1:30 pm
Patient name: Rachel Green
Age: 29
Sex: Female
Complaint: Patient complaints about the increase in frequency of urination and burning sensation when urinating.
History: Patient has the history of type 2 diabetes and urinary tract infection from time to time.
Physical exam of the patient:
The temperature is 100.4 °F.
Heartbeat is 94 beats/min.
Blood pressure is 130/90 mmHg.
Diagnosis: Urinary Tract Infection
Assessment: Patient is anxious and discomfort in lower abdominal region. Urine dipstick shows following results.
2+leukocytes which indicate infection.
1+ Nitrates which indicate the presence of bacteria such as Escherichia coli.
1+ blood which indicates the infection or injury to urinary tract.
Evaluation: Antibiotics are given, advised to take more fluids, and show up after 2 days if the symptoms remain. The patient feels no burning sensation after the antibiotic’s medication.
Conclusion
Nursing notes are an essential part of nursing, which provides detailed information about the patient’s health and condition. Nursing notes provide clear communication among the healthcare providers and serve as a legal document if there is any kind of conflict. It is important to write effective nursing notes by adhering to key elements and standard format such as SOAP, DAR, and PIE. In this blog we have discussed the importance of nursing notes, tips on how to write an effective nursing note with some nursing note examples.
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