Writing Nursing Notes

[Braveheart]

Can any of you seasoned veterans recomend resources for writing effective nursing notes. As a new nurse I am finding this to be one of my biggest challenges.

[Aaron C.]

Nursing Notes

Try that website or email Kris Brookshire for help.

I don't know this person so I cannot endorse them, but I just found that site by doing a quick google search for nursing notes.

In my opinion, THEY SUCK. You spend a certain percentage of your day passing pills, and doing admits and discharges, and the rest of your day, about 85% is spent writing nursing notes to cover your hole. I think it's messed up how critical people are over nursing notes, but it'll never change.

What really pisses me off is nursing notes and charting are HIGHLY scrutinized while doctors handwriting is flat out brutal but NOTHING is ever said or done about it. How many hours of your work week are spent trying to decipher doctor's orders? How many times is the wrong thing "interpreted" by the group of nurses who had to gather to determine what the words said and how many lives has it cost? Make them freakin' print that crap or make it 100% legible.

Sorry for the rant.

[SilverBells]

Practice is key, also you will learn certain things to shorten them. IE: you are going to say the same thing about similar patients many times. I have a "standard" discharge note, which covers all the d/c stuff, legal stuff etc. By now, I have it memorized, so I just zip it right out each time I d/c someone.

I'd warn you though not to take too many short cuts- I just started at a facility as a traveller, and though they say I chart too much, I'd say based on their charting, there is a lawsuit waiting to happen.

[nursinghumor]

Get into the habit of writing each note the exact same way. Start from the head (neuro) and work your way down. When in doubt, chart about it. When a patient falls, or goes bad, take the extra time to provide a detailed account of what you did for them.

Give enough information for the next shift, or next day's staff to get a clear picture of what was going on with the patient.

Eventually you strike a balance between writing speed and legibility.

Andrew Lopez, RN
http://www.4nursing.com