How to Write Nursing Notes: Key Information to Know About
Nursing notes are written records kept by the nurse to document patient care. Why are they essential? They facilitate communication between healthcare providers, help monitor the patient’s condition, and ensure continuous care.
Nursing progress notes should contain objective and factual information about a patient’s vital signs, symptoms, interventions, medications administered, as well as health condition changes and treatment responses. Avoid here personal opinions or assumptions.
What Is Nursing Note Format and How to Organize It?
To keep clear and consistent documentation, using a structured format with headings and subheadings is vital. The first format you can follow is DAR:
- Response format
Also, the most popular is SOAP you can follow:
- Subjective information that the patient or family members provide. This may include complaints, pain levels, or statements about their condition.
- Objective section in SOAP nursing notes consists of measurable data like vital signs, physical assessments, lab results, and observations made by the nurse.
- Assessment section is where nursing specialist notes and interpret the data collected and provide their professional judgment, e.g., any problems detected or nursing diagnosis.
- Plan section outlines the actions taken or planned to address the patient’s needs, including prescribing medications, consulting with other healthcare providers, or planning follow-up care.
How Often Is It Necessary to Write Nursing Progress Notes?
Notes on nursing should be written regularly, typically at the start of your shift and whenever there is a change in the patient’s condition. To accurately track the patient’s condition, it is important to document all information in a timely manner.
Avoiding common mistakes is also crucial to knowing how to write nursing notes. Some of them are the following:
- Using jargon or abbreviations that are not universally understood,
- Being too vague or subjective.
- Leaving out important information.
- Failing to sign and date your entries.
- Forgetting the facility’s documentation policies.
Many healthcare facilities also use electronic health record (EHR) systems with various document templates & forms. You may familiarize yourself with some of them when learning how to take notes in nursing school to be prepared to face documentation types used in your workplace.