How to write nursing notes: an ultimate guide

**Collaborative post**

As a student, when you’re writing anything, you do so to communicate something to another person. For the nursing student, you will often, if not always, write notes to communicate with a target group, who could be your fellow nurses, your nursing manager, or other leaders within your workplace. You should always have in mind the importance of nursing notes, as they represent legal documents. As you have noticed in your profession, the nursing notes comprise various information types concerning patients, including their historical data, treatment methods, and the care they are receiving while under the supervision of the nurse. The note should demonstrate you have been observing the patient effectively, as the data can be used to improve the patient’s outcomes.

Considerations for nursing notes

Before writing the nursing note, there are various factors to consider. As you have learned, the nursing profession is guided by various standards that translate even into documentation. Consequently, there are four components that a nursing note should adhere to:

• Subjectivity – The nursing note should be subjective, in relation to the patient’s individual description of their injuries, signs, pain, and other outstanding health issues. Basically, listen to the patient, then write it down. If the patient is accompanied by a family member, listen to them as well and collect as much critical information as possible.
• Objectivity – This means the nurse should collect all types of data, including the observable signs, like swollen areas, bruises, and discolored skin. Also, measure and record numeric data, like heart rate and blood pressure. 
• Assessment – As a nursing student, you should have the ability to assess the patient’s issue. Record aspects like how severe the patient is, changes that have occurred since admission, and the available symptoms that could be used to confirm a diagnosis.
• Plan – The final element includes defining the steps to take to care for the patient, including tests, medication, and future assessments. 

Points to note when recording notes

1. Will the information assist other professionals who will interact with the patient?
2. Did the notes summarize the patient’s present predicament?
3. Would the notes remind you about the patient’s issue and care, five years into the future, if a legal case arose?

What do I record on nursing notes?

• How a patient feels, alertness, drowsiness, confusion, etc. 
• Whether the patient can move freely
• Blood glucose
• Any concern the patient presents
• Medication history
• Food and fluid consumption
• Pain levels
• Abnormal test results
• Care handover 

What you should not record

Some of the information collected from patients may be irrelevant or too private to record on a nursing note. Notably, you should only record factual information, instead of giving your opinion. As highlighted by the Lippincott Nursing Center, a nurse can share their opinions to other professionals to gain an advanced view of the patient’s condition. Nevertheless, some information should not be recorded;

• Private information about the patient’s family and friends
• Conversations about the patient with other nurses or professionals
• Abbreviations that are error-prone as highlighted by the ISMP
• The nurse’s private opinions
• Negative perspectives from other professionals regarding the patient’s care.

Illustrations of nursing notes

Below we provide illustrations of excellent nursing notes that offer students more context.

• When I entered the room, the patient appeared blue and had breathing difficulties. I shouted Code Blue and began CPR. The emergency team then arrived. 
• The patient is breathing adequately. Pink coloration. No symptoms of breathing issues. The patient eats his food and hydrates regularly while weight is retained. The patient is moving effectively. Family provides support.
• Patients can make decisions. Vital signs 139/74, 68, 97.1, 19, 96% RA.

Tips on writing concise nursing notes

As we have learned, the documentation process for nursing professionals is critical, influencing their work and the patient’s outcomes. So, the nurse should assess various elements before writing or sharing their nursing notes, which are also noted by the American Nurses Association;

1. Ensure the information is clear and legible – As a nurse, you should always be concise regarding your communication, meaning you need to get straight to the point. Your notes should comprise a detailed summary, that provides a clear picture of the situation. Avoid lengthy wording to ensure the observation and interventions are clearly noticeable while also saving you unnecessary work.
2. Write everything down – when you are interacting with the patient, you should ensure each element of information pertaining to their condition and experience is recorded. In addition, the notes should highlight conversations with the family members and professionals who interacted with the patient. Noting the information will be critical in future references and should include the legal names of everyone who engaged in the process.
3. Avoid abbreviations – As noted earlier, abbreviations could have a diverse number of meanings, which could affect the decisions about a patient’s care, including medication. Abbreviations could also be determined differently by readers, which could lead to misconceptions
4. Keep the information updated on various platforms – A nurse could record the data on hard or soft copies. But it is critical they ensure they record information as they receive it, especially during the interaction with the patient. The data should be immediate to ensure accuracy. This assists the nurse to avoid mistakes presented in the notes, which could be fatal. If you have done NCLEX preparation for foreign nurses, this will be easier for you.

Recording nursing notes represents an essential component of the profession. Using the above skills and guidelines, you can take effective notes that will be applied to enhance the care outcomes for patients. During the process, you are required to understand why you are writing and the information that could be used by other professionals. Proper understanding of the notes means you don’t have to plagiarize another nurse’s notes. Also, it is not about how much information you write but the concise and clear nature of your written material.