Nursing Notes Notes are critical to patient care. They must be detailed and accurate, yet not go on and on so that the reader gets uninterested. Notes should always be clear and precise, and it's a good idea to go back and read them after you entered them. Read them as if you did not write them, and as if you are reading them from someone else. Documenting Documentation is vital in a nursing role. Lack of documentation is a serious mistake, and is not tolerated by medical facilities. Many nurses put the emphasis on patient care, which is great, however documentation is part of that patient care. Nurses are busy, everyone knows and understands that, sometimes there is not a moment to breath, and it's hard to find time to document. The document portion of the job should be considered as important as medication administration, it must be done. Often the busiest times are the times that require the most extensive documentation, it's actually an extension of the busy time in many cases. Schedule your day so that you allow for adequate time to document, even if it means you stay beyond your shift ending. If you feel you need assistance in arranging a time to document, speak with your supervisor and ask for help. Related: Insomnia in Nurses Prioritize Documentation Critical lab reports require immediate attention. Most facilities require them to be reported to the head nurse, followed by the patient's physician. Other documentation that would be considered critical would beThe patient is very confused and unaware of surroundings, when this is not normally the case. A patient falls, which requires an incident report, but should also be documented in your notes A patient talks of suicide or there are indications they could be suicidal. Never use generic statements, such as the patient's doctor called. Why did they call, what did they say, did they leave orders? Be complete when providing this information. Note Examples Unacceptable Note -Mr. Blank was irritable today and got sick. Doctor called. -Blank was throwing up the doctor said give medication -Mrs. Blank asked for extra pain medication at 12 -Blank was very upset, but later calmed down
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