Tips about Nurse's Notes
While you will see many different styles of nurse's notes, the most important
thing is that you are including the most relevant information about your patient.
Some nurses chart a great deal, and some seem to say a lot with a few short
notes. Just remember to be concise but thorough.
Here are a few things that I like to see included in Nurse's notes:
An opening note, a closing note, and at least several middle notes
The opening note needs to include that you got report from the night nurse,
you have assessed your patient, any treatments or prn medicines that you
gave first thing in the morning, your discussion of your plan of care with
your patient including your goals and interventions, and safety issues.
You do not need to re-write your entire assessment in the opening note.
Only include information that is out of the ordinary. You will have already
charted your assessment in another place.
An example of an opening note might look something like this:
0730 Received report from the night nurse and assumed
care. Assessment completed. VSS. Pt awake, alert and
oriented. Complains of pain as an 8 on a scale of 1-10 in
fractured right hip. Medicated with two Vicodin per MD
orders. Will continue to monitor. IV site to L FA CDI. D5.5
NS with 20meq of KCL infusing at 75cc/hr. Discussed
plan of care with patient. Goals are to have pain level at
or below a 5 for the duration of the day and for patient to
walk around nurse's station at least once by the end of
the shift. Patient verbalized understanding. Call light
within reach and siderails up X 2.
The middle notes need to contain information of the things that are happening
throughout the day such as IV site changes, teaching done, changes in
assessment, evaluation of interventions, leaving and coming back from
procedures (include a short assessment when the patient comes back from any
procedure), psychosocial issues, etc.
An example of some middle notes might look something
like this:
0830 Reassessed patient's pain and it is
now a 4 on a scale of 1-10. Patient
resting comfortably. Did teaching with
patient on the important of calling early
for pain medication before the pain gets
severe. Patient verbalized understanding
and stated that he would try to stay on
top of it from now on. Will continue to
0915 Ate 100% of breakfast. Walked
with pt. to the door and back. No SOB
noted. Pt states "It hurts to walk but I
know that it's important." AM meds
given. States he wants to take a short
1015 Pt down to X-ray. Changed sheets
on bed.
1045 Pt back from X-ray. VSS. No
complaints of pain or discomfort. IV site
infiltrated while patient was in X-ray.
DC'd the old site and started a new on in
the R hand X 1 attempt with 22g. Flushes
well and IVF continue to infuse at 75
1200 Pt took a shower with minimal
assist. Complained of pain as a 5 on a
scale from 1-10. Medicated with 1
Vicodin. Will continue to monitor.
1230 Walked with patient to nurse's
station and back one time. Pt stated he
was very happy that he got to walk that
far and states he will continue to walk
throughout the afternoon. No complaints
of pain. Pt eating lunch.
The closing note should include a wrap-up of any information or evaluations not
yet discussed. It should include that you gave report to the primary nurse and the
state of the patient when you left.
An example of a closing note might look something like
1300 Gave report to primary nurse and
PCT. Pt is resting in bed with no
complaints of pain or discomfort. Pt
states he will walk after he gets up from
his afternoon nap. VSS. No change in
assessment. Siderails up X2 and call light
in reach.
These are just examples and you will find your own voice when you chart.
Remember that your charting should tell the story of what happened during the
day. Try to chart when events happen rather than waiting until the end of the
day. It's very easy to forget things. Use only hospital approved abbreviations and
never make up your own abbreviations. The plan of care is your nursing care plan
for this patient. Make sure you really focus on doing the interventions and try to
achieve the goals. This is what real nursing is all about!

Tips on Nurse Notes