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What is a nursing note?

A nursing note is a medical note that serves as a record of nursing care including evaluation, assessment, diagnosis, planning, delivery of care to a patient, and evaluation of such interventions. Such notes are documented by qualified nurses or other providers under the direction of a qualified nurse.1 The purpose of nursing notes is to include clear, accurate descriptions of nursing assessments, changes in patient conditions, the specific care provided, and all necessary information to support optimal communication, collaboration, and continuity of care.

On this page, we’ll discuss the importance of nursing notes and how they help all members of a patient’s healthcare team make informed, appropriate decisions for patient care. We’ll also cover the many additional purposes of electronic nursing notes.

What kind of information comprises a nursing note?

Nursing notes document the nurse’s decision-making process to assess the patient; systematically collect, analyze, and organize clinical data; implement a treatment plan using evidence-based practice (EBP); and evaluate the effectiveness of interventions and treatments. The objective of the plan of care is to personalize and tailor the treatment plan based on the patient’s individual specific physical, emotional, spiritual, and cultural needs to achieve optimal outcomes.

Before the widespread use of electronic health records (EHRs), nursing notes were handwritten. Therefore, nurses needed to ensure that the patient’s health record began with an identification sheet. That may still be the case in some healthcare facilities. However, for those who are using the Practice Fusion EHR, your patient’s chart will include the same information that was traditionally recorded on an identification sheet. In addition, when you start new notes in Practice Fusion, the patient’s full name, date of birth, and the date of the visit will populate.

New patients will provide your practice with the required demographic information upon registration and check-in, including the following:

  • Full name
  • Date of birth
  • Address
  • Phone number
  • Email address
  • Social security number
  • Emergency contact
  • Married status
  • Next of kin
  • Caregiver’s full name and contact information (if applicable)
  • Preferred language
  • Race
  • Ethnicity

They’ll also provide additional information, including their driver’s license, insurance card, a signed HIPAA agreement, and other documentation required by your practice.

The information included in a nursing note typically follows the nursing process, providing a framework for clinical reasoning and a systemic guide to patient-centered care with five steps: assessment, diagnosis, planning, implementation, and evaluation.2 According to the American Nurses Association (ANA), the nursing process is the “common thread uniting different types of nurses who work in varied areas [and is] the essential core of practice for the registered nurse to deliver holistic, patient-focused care.2

1. Assessment

As noted above, a nursing assessment begins with obtaining all information regarding a patient’s specific physiological, psychological, emotional, sociological, and spiritual needs. The assessment in a nursing note also documents the following:

  • Subjective data, which describes the personal thoughts and feelings of the patient or a person close to him or her
  • Objective information that the nurse obtained during the patient’s encounter. This may include vital signs, including heart rate, respiratory rate, blood pressure, and temperature; height and weight; physical examination; pain level using an appropriate pain scale, if applicable; and baseline or follow-up assessment of the patient’s mental state. In addition, the note’s objective data may include laboratory and imaging results, additional diagnostic data, and review of documentation from other healthcare providers who are also part of the patient’s healthcare team.3
  • Past Medical History (PMH)
  • Past Surgical History (PSH), including surgery dates and reports
  • Family History, including certain conditions or diseases in family members (e.g., a history of heart disease, diabetes, Parkinson’s disease, cancer, etc.)
  • Social History, including marriage status, family situation, occupation, education, and habits, e.g., smoking status, alcohol consumption, diet, exercise, religion, and sexual history
  • Psychosocial History, such as mental, psychological, and behavioral health
  • Current and Past Medications
  • Allergies to medications, foods, or other allergens, such as dust mites, animal dander, latex, etc.
  • Immunizations and dates, e.g., for influenza, pneumonia, COVID-19, shingles, and required pediatric vaccinations
  • Obstetric History, including pregnancies, any complications, and pregnancy outcomes

While conducting an assessment, nurses may also do the following:

  • Elaborate when documenting a body system abnormality with each assessment.
  • Indicate whether the assessment was visible, audible (e.g., percussion), or tactile (e.g., via palpation).
  • Use quantifiable data with descriptions. For example, if nurses need to describe the size or shape of wounds yet do not have access to a measurement device or if the shape of a wound isn’t easily describable, they can reference common objects such as a dime, quarter, or soda can for reference.

2. Diagnosis

Based on analysis of normal and abnormal patient physiology, the nurse formulates a diagnosis through using his or her clinical judgment, which in turn helps to determine and prioritize necessary interventions and treatments based on patient-centered outcomes.

3. Planning

During the planning stage of the nursing process, nurses develop a care plan that incorporates patient-specific goals, potential outcomes, and interventions based on EBP guidelines. These guidelines provide nurses and other healthcare providers with evidence-based research data that is obtained, analyzed, and condensed by experts in the field in question into specific clinical practice recommendations.

Nursing care plans are key components of this planning and goal-setting stage, as they provide the following:

  • A formal process for accurately identifying current needs and recognizing potential needs or harms
  • Specifying the direction for providing tailored care to fulfill a patient’s unique care needs

Nursing care plans communicate critical information to all members of the patient’s healthcare team, including other nurses, other healthcare providers, and the patients themselves, helping to ensure proper coordination, quality, consistency, and continuity of care.

4. Implementation

During implementation, the nursing interventions discussed in the plan of care are carried out, such as providing oxygen, direct care, indirect care, standard treatments, medication administration, and EBP protocols.1

5. Evaluation

Evaluation is the last step in the nursing process. Following the implementation of care, nurses evaluate whether the desired outcome has been fulfilled. Depending on the patient’s condition, a nurse may need to reassess the patient repeatedly and adapt the plan of care based on the results of the reassessment.

How can nursing notes be used?

Nursing notes can be used for various purposes including the following:

  • Assessing proper medical care
  • Validating reimbursements from insurance companies
  • Ensuring compliance with regulations from federal governmental agencies, such as Medicare and Medicaid, as well as state and institutional regulations
  • Ensuring compliance with agencies that perform accreditation and establish healthcare delivery standards, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA), and the Accreditation Association for Ambulatory HealthCare (AAAHC).6
  • Protect against malpractice or negligence allegations

How an Electronic Health Record can help

An EHR is set up to help ensure that nursing notes are complete and accurate. When documenting a note in the Practice Fusion EHR system, nurses have the ability to easily and efficiently pull forward data from the patient’s chart into a new encounter note, including active medical history, PMH, PSH, family history, current medications, and allergies.

Nursing notes can help tell your patient’s clinical story and include a tailored plan based on the patient’s specific physical, psychological, spiritual, and cultural needs to achieve optimal outcomes.7

The Practice Fusion EHR system focuses on enabling nurses and other healthcare providers to capture a patient’s key clinical data efficiently and effectively and to document medical notes in a manner that assists in optimal continuity of care among all members of a patient’s healthcare team. The EHR enables nurses and other healthcare providers to share medical notes and other chart data securely and quickly with other ambulatory practices, hospitals, laboratories, imaging centers, clinics, and, of course, patients themselves– increasing interoperability and enhancing patient care.

Click here to learn more about the Practice Fusion EHR.

References:

  1. Toney-Butler, TJ, Thayer JM. Nursing process. StatPearls Publishing. Jan 2021. Updated July 9, 2021. Accessed September 23, 2021: pubmed.ncbi.nlm.nih.gov
  2. American Nurses Association (ANA). The Nursing Process. Accessed on September 23, 2021: https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/
  3. Podder V, Lew V., Ghassemzadeh S. SOAP notes. StatPearls (Internet). Last updated: September 3, 2020. Accessed on September 15, 2021. https://www.ncbi.nlm.nih.gov/books/NBK482263/
  4. Project Smart. 2021. 21 ways to excel at project management (e-book). Accessed September 23, 2021: https://www.projectsmart.co.uk/smart-goals/brief-history-of-smart-goals.php
  5. Doran, GT. There’s a S.M.A.R.T. way to write management’s goals and objectives. Management Review. 1981. 70(11): 35-36. Accessed September 23, 2021: https://community.mis.temple.edu/mis0855002fall2015/files/2015/10/S.M.A.R.T-Way-Management-Review.pdf
  6. Viswanathan HN, Salmon JW. Accrediting organizations and quality improvement. Am J Manag Care. Oct 2000. 6(10):1117-30. Accessed September 23, 2021: https://pubmed.ncbi.nlm.nih.gov/11184667/
  7. Robey T. Stating the Art and Science: The art of writing patient record notes. AMA Journal of Ethics: Illuminating the Art of Medicine. July 2011. Accessed on September 17, 2021. https://journalofethics.ama-assn.org/article/art-writing-patient-record-notes/2011-07.