To write nurse’s notes, use a consistent format, ensure notes are timely, use standard abbreviations and remain objective. Avoid including information that does not directly relate to the patient’s health.
Use a consistent format for each record starting with the patient’s identification information. Ensure that each entry includes the time and date of the report and your full name. Keep the record simple to make it easy for doctors and nurses on the next shift to gather information quickly. Use readable and clear handwriting for handwritten notes.
Next, note the type of care given and personal observations as soon as possible to avoid passing on faulty information. Ideally, the notes should be written within 24 hours of supervising patient care.
Use standard medical abbreviations where necessary to ensure that the attending physician and other nurses can clearly understand your notes. Use complete terms whenever possible.
Lastly, only include what you hear and see in the nurse’s notes. Avoid writing personal interpretations of a patient’s condition or subjective comments. Note down all the important information gathered from conversations with other nurses, doctors and family members, and use quotation marks for this information. This makes it easier to keep a comprehensive record of patient information.