Nurses who work in care homes or nursing homes write nursing progress notes to record each patient’s recovery and care. These notes include important information about the patient, such as the patient’s medical history, current symptoms and response to treatment. Nursing progress notes also serve as a record of the patient’s time spent in the facility. If you are a nurse, here are some tips on how to write good nursing notes:
1. Gather subjective evidence:
After recording the date, time and the patient’s name, you should request information from the patient. This information will be subjective and limited to the patient’s knowledge and perspective. However, it is still essential. Subjective evidence comes from the patient themselves and reflects their experiences. This can include things such as the patient’s symptoms and concerns.
2. Use a systematic approach:
Documentation is a vital part of your job as a nurse. Instead of completing your nursing notes at the end of the shift, write as you go. This will ensure that everything you document is fresh in your mind and, therefore, accurate and up-to-date. This involves describing what happened, providing a clinical/nursing assessment and explaining what was done about the situation.
3. Include the important information and nothing else:
When it comes to nursing progress notes, the goal is to strike a balance between being detailed and concise. However, it’s important to include only necessary information that will make the progress notes more difficult to read. Always ask yourself why you include certain details when writing your progress notes. Are they part of a clinical analysis or change in conditions or care?
4. Record your assessment:
Record notes about the patient’s condition based on the conclusions you draw from the patient’s symptoms. Your assessment should include the medication administered and the patient’s response. Try to notice changes in the patient’s appearance and record them as accurately as possible.
5. Use professional and matter-of-fact language:
It is important to use professional, matter-of-fact language in progress notes for a variety of reasons.
- Progress notes are often read by fellow nurses.
- The patient and his or her loved ones may also read the notes.
6. Be careful with your handwriting:
Paper-based nursing charts are still in use in many care homes and it is important to be careful with both your handwriting. When you are making nursing notes, you must ensure that your handwriting is legible. If nobody can read your notes, they will fail to serve the purpose for which they are being maintained. Moreover, illegible handwriting will lead to confusion which can cause medical errors.
7. Use standardised abbreviations:
Write out complete terms whenever possible. An abbreviation can mean different things to n different people. Only use standardised and pre-approved abbreviations.
8. Detail a care plan:
The care plan is one of the most important sections of a nursing progress note. This is where you and the doctor detail the course of action you plan to take for the patient’s benefit. For example, if the patient has an upcoming tes,, you could mention it in the progress note. If the patient has refused to take the test, that must also be documented.
Many nursing homes in the UK are using different types of electronic health record systems to maintain digital records. Electronic MAR is an Electronic Medicine Administration Record System that can help streamline medication documentation and administration. Digital MAR Sheet template works as an app on Android smartphones and tablets.
If your care home or nursing home is using an eMAR, make sure you receive eMAR chart training so that you know all its features that will make your daily paperwork efficient. Here’s a useful read on the benefits of eMAR.