What Type of Notes Do Nurses Include in Their Charts?


Quick Answer

Nurses include flowcharts, care plans and narratives about patients in their medical chart notes, according to Purdue Online Writing Lab. Nurses must be objective and precise when writing their nursing charts.

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Full Answer

Nursing flowcharts are generally part of every health care facility's medical record keeping procedure, notes Purdue Online Writing Lab. A nursing care plan includes the problem's definition, intervention and evaluation. It is not a diagnosis of a patient's condition. Every intervention must be appropriate for the specific patient, and the evaluations should be measurable and have a time frame for success.

Nurses should use the narrative to record a patient's history and treatment during their visit or stay. It should also include all communication with other medical professionals regarding the patients treatment, notes Purdue Online Writing Lab.

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