15 January 2019

Nursing documentation: How to write a patient's notes

pen

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.

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.

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.

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

Examples of what you should be recording are:

  • 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 

Do you have any tips for writing patient notes? Let us know in the comments. 

Sources

Fastaff Travel Nursing

PMC

Nursing Standard