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Latest News from Marian College, School of Nursing

Tips on Writing Nursing Notes

The ability to write efficient nursing notes is an important part of a nursing job. It is crucial to create a system that helps you keep all the details and observations together. Here are several easy tips to make your nursing note documentation clear and organized.

  1. Be consistent and use the same format all the time.
  2. Make sure each record starts with the patient’s identification information.
  3. Write your notes as soon as possible and not later than 24 hours after the event.
  4. Each entry should include date and time as well as your full name.
  5. Use objectives instead of subjective feelings.
  6. Don’t use anything other than standard abbreviations.
  7. Take notes from any communication with family members, doctors and other nurses regarding a patient’s health.
  8. Use “this nurse” instead of “I’ in your professional notes.
  9. Always use only full names.
  10. Use quotation marks to take notes of the communication.
  11. Don’t include any irrelevant information.
  12. Always remember that a patient has a right to see your records.

Using these simple rules you will be able to maintain clear and professional records from shift to shift. Don’t forget that if you didn’t take notes of what you did it may be considered as “it never happened”.

Read about more easy tips to follow on managing life as a vocational nurse.

 

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