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Nursing documentation: How to write a patient's notes

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Nursing documentation: How to write a patient's notes

Writing a patient's notes is one of the primary responsibilities within the nursing profession. At the start, it can be daunting. However, it's integral to delivering top-quality care.

Regardless of the form of the records (i.e. electronic or paper), good clinical record keeping should enable continuity of care and should enhance communication between different healthcare professionals. Here are some tips on how to write concise patient notes.

Ensure your writing is clear and legible

Illegible handwriting can lead to a patient receiving the wrong medication or an incorrect dosage of the right medication. This can have serious, or even fatal, consequences. Keep your writing as neat as possible and use a pen that produces clean lines and doesn’t smudge.

Note all communication

Jot down everything important you hear regarding a patient's health during conversations with family members, doctors and other nurses. This will ensure all available information on the patient has been charted. Always designate communication with quotation marks as this makes your notes as clear as possible.

Write as often as you can

Write your notes within 24 hours after supervising the patient's care. Writing down your observations and noting care given must be done while it is fresh in your memory, so no faulty information is passed along. Writing notes within this time is a very good habit to get into as a nurse as you’ll find that it starts coming naturally over time.

Try the PIE format

PIE stands for problem, intervention and evaluation. Writing in this format allows your colleagues to see what steps you've taken to resolve any problems.

e.g. Problem: Patient's oxygen levels dropped. Intervention: Patient was given one litre of oxygen via nasal specs. Evaluation: Patient's oxygen saturations increased - continue to monitor.

Know what sort of things to record

A lot can happen during your time with a patient, so it can be tricky to decide what needs to be included in their notes. Here are some examples of what you should be recording:

  • Care takeover

  • How the patient is feeling - alert, drowsy, confused etc

  • Mobility

  • Blood glucose

  • Concerns

  • Medications

  • Food and fluid intake

  • Bladder

  • Bowels

  • Pain

  • Abnormal readings

The more you write patient notes as a nurse the more you’ll get used to what needs to be included and what’s important. We hope that this guide has helped with some of the note writing queries you may have so that you can feel more confident going forward.

For more tips for nurses, take a look at our healthcare news.