In the medical field, large amounts of information must be circulated between patients, doctors, and nursing professionals. Often, preserving this information is done using notes that are taken by nurses, entered into patient records, and examined by whoever may need them. Using the following tips, nurse practitioners can write accurate and consistent notes that vastly improve the process of securing desirable patient outcomes.
1. Standardized note-taking forms save time and effort
To make note-taking more consistent and to expedite the process of exporting the information into medical records, it is beneficial to stick to the same format when writing notes. Having a go-to outline or form for recording important notes or highlights from interactions with patients and medical personnel ensures that nurses won’t need to spend their time sorting through notes before using them. It is also important to be precise, and to use completely legible handwriting when digital charting systems are not available. [2] Medical records are usually legal documents, so when notes or records need to be changed due to an error, always make sure edits are approved by a nurse administrator.
2. Take notes immediately, don’t wait
Medical facilities are fast-paced work environments, so nurses should always take their notes as soon as the opportunity arises. If note-taking is put off for too long, other higher priority events may occur, distracting nurses from recording important information. As time passes and new situations arise, nurses may forget critical patient information that should have been recorded. This could be hazardous, as not communicating important details may lead to a negative outcome for a patient.
3. Be wary of slang, jargon, and abbreviations
Using shorthand phrases can invalidate a nurse’s notes, as other medical professionals who are accessing them may not recognize the language being used. Making the assumption that all colleagues understand uncommon professional jargon could be problematic, as the medical professional who is reading it might not understand the message that the nurse means to convey. If an important message is misunderstood, administering improper treatment to a patient is a risk.
4. Only record facts and important events
When constructing notes, including only factual, first-hand information is the best way to ensure that medical records are accurate and helpful. Even when there are many events occurring at once, nurses must also focus on recording notes in consecutive order, as the events occur. While maintaining consistency, nurses should still always be aware of confidentiality when taking notes. Patients and their caretakers may request access to their medical records, so to avoid conflicts, it is important to be entirely honest while remaining mindful of disclosing confidential information when taking notes for medical records.
5. Record any relevant observations and information
Important information that can’t be categorized as an “event” should also be recorded based on what the nurse believes to be important to the patient’s treatment. [1] In many cases, notes of important biological metrics like visual acuity, blood pressure, pulse, temperature, and respiration diagnostics can be beneficial when taken regularly. This is best done using the data featured in charts, and later filing the charts into the notes once the patient is discharged. Actively taking notes of what will happen after the patient is discharged, and recording plans for future treatment can be helpful as well. [1]These notes can range from which medicines will be prescribed, to plans to schedule a follow-up appointment with the patient to verify their ability to stick to prescribed plans.
6. Date and sign all documents
For the sake of organized and consistent recordkeeping, nurses should also add the date that each note was taken, and add their signature so other medical personnel can verify that the notes were not forged. Consent forms and other important documentation should also be double-checked for patient signatures.
Note-taking is not a glamorous nursing skill, but it is an immensely important one. Understanding what to document, when to record certain data, the proper way to organize notes, and how to convey important medical information, will improve a nursing professional’s ability to provide value to their patients. Through an accredited Master’s of Science in Nursing degree program, nursing professionals can enhance their ability to take useful notes that accelerate the process of treating patients.
Learn More
Health care is a dynamic and ever-evolving field, and more is now expected of nurse leaders. In fact, the American Association of Colleges of Nursing (AACN) has called for a doctoral level education to become the requirement for advanced practice nursing. Earning an online Doctor of Nursing Practice (DNP) puts MSN-credentialed nurses like you at the forefront of the industry — prepared for leadership, nurse education, patient care, and to shape future policies and procedures in health care.
Source
1. US National Library of Medicine – National Institutes of Health
2. Nurse Labs