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 monitor. 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 nap. 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 cc/hr. 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 this: 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!