What is a nursing note?
A nursing note is a medical note into a medical or health record made by a nurse that can provide an accurate reflection of nursing assessments, changes in patient conditions, care provided and relevant information to support the clinical team to deliver excellent care.
Complete and accurate nursing notes are crucial to make good decisions for patient care. Nursing notes should provide a clear and accurate picture of the patient while under the care of the healthcare team. Federal, state, and institutional regulations require that nursing notes follow broad guidelines to determine if a nurse’s action was reasonable and prudent.
What does a nursing note consist of?
In addition, to the type of information found on the medical note page, nursing notes should follow these guidelines:
- Always include interventions initiated and the patient response when documenting an acute abnormality found during assessment
- Always elaborate when documenting a body system abnormality with each assessment
- Always include if an assessment was visual, audible, and/or tactile
- Reconcile mismatched objective and subjective assessment findings
- Document the patient’s baseline mental status
- Always assess the patient at the time of discharge or transfer.
- Use quantifiable data with descriptions. Reference to common objects, such as a quarter or soda can, to describe the size or shape of wounds may be useful with awkward shapes or when there isn’t access to a measurement device.
How will nursing notes be used?
Nursing notes can be used for various purposes from assessing proper medical care to malpractice litigation. Thus it is important that nurses write their nursing notes with various audiences in mind:
- The Healthcare Team: Nursing notes provide a healthcare team a complete and accurate timeline of a patient’s health status and care. This is key to determining a diagnosis and further care.
- The Nurse: Nursing notes should be complete enough to jog a nurse’s memory if any details are not clear or hazy. In the unfortunate case that a nurse must testify for a lawsuit, clear and accurate nursing notes serve to ensure the details of a nurses care.
- The Lawyers, Judge, and Jury: Clear, comprehensive nursing notes ensure if our judicial system can determine if a patient’s nursing care was reasonable and prudent.
How an Electronic Health Record can help
An electronic health record, or EHR, is set up to ensure that nursing notes are complete and accurate. With good EHR software and EHR systems, nurses will be alerted to any missing, incomplete, or possibly inaccurate nursing notes.
An EHR also guarantees all of a patient’s nursing notes are never lost and stored in one easy to access location. Professionals can make sure they have all the information to provide the best care possible, and patients can make sure they always have access to all their nursing notes.
Check out Practice Fusion’s EHR system to guarantee complete and accurate nursing notes and cloud-based storage for easy access.