Examples of items to include in nursing notes are transfers, anomalous vital signs, codes and notations of physician's orders, according to NurseTogether. It is important to be as specific as possible to avoid later misinterpretation.Continue Reading
General statements made when the nurse is feeling harried by a pile of paperwork often lead to significant misinterpretations later, states NurseTogether. For example, instead of simply noting "Dr. Friend called," a more effective note reads "Dr. Friend paged, assessment result discussed, no additional orders at the present time."
Different hospitals use different charting methods, but nursing notes should always be easy to read; free of blurs or erasures; free of spelling and grammar mistakes; objective; and completed in black or blue ink. In all cases, the notes should include the names of any staff the nurse notified about a particular situation and the steps taken by the medical team, reports NurseTogether.
One common mistake in nursing notes is to assume new reports of pain have the same cause as earlier reports or the nurse knows what is going on without an evaluation. In one case, a patient fell and struck his head in the hospital and complained about an intense headache. The nurse noted it as a "migraine" even though the patient had no history of migraine. A CT scan done 12 hours later showed herniation in the brain stem. A thorough evaluation and documentation would have resulted in correct diagnosis hours earlier, explains NurseTogether.Learn more about Diagnostics & Imaging