Nursing documentation notes include records of care provided by a nurse to a patient, the patient's response to care and any events or significant interactions that occurred while the nurse was with the patient. These notes communicate essential care-related information to other nurses and providers working with the patient.Continue Reading
The information the nurse provides ensures a smooth transition and seamless quality of patient care when shift changes occur. Nurses strive for accuracy and objectivity when documenting patient care. Notes are thorough, but to the point, easily read and understood. Subjective or negative notes regarding the patient or the care provided by a colleague are not appropriate in a nurse's documentation notes. Nurses record only their own actions and only after the actions have occurred. For example, a nurse does not record that medication was given to the patient prior to administering the medication.
Documentation templates usually include assessment of the patient's condition, needed care as identified through the assessment, the care that was delivered, and an evaluation of its impact on the patient's condition. Documentation notes also include medications given and vital signs, such as blood pressure, temperature and blood oxygen levels. Nurses sign and date all patient documentation notes.
Electronic documentation is used in many medical settings and specific rules regarding the documentation of patient care vary by institution.Learn more about Careers