Make Your Own Nursing Note Templates (Samples & Examples)

free nursing note template 7

A nursing note template is used by nurses to take notes on every interaction they have with patients. In medical emergencies, the nurse is one of the front liners. Nurse notes are very important for the nurses because they administer drugs to patients in the hospital.

Progress notes on nursing:

Commonly speaking, nurses are patient advocates. They spend the most time with patients. Making nursing notes gives you a complete picture of the patient’s health. Then, other medical specialists and professionals can use this in making diagnoses or suggesting treatments. Moreover, while charting patients, these notes are a form of official documentation made by nurses. In your nurses’ notes templates, you write down essential information depending on the scribbling and notations you collect during your visits with the patients.

It is extremely important to keep accurate and thorough notes. It also maintains effective communication between you and the rest of the medical staff. You should also check Nursing Assessment Forms.

The benefits of writing nursing notes:

Nursing notes usually contain a patient’s general and basic information. It can include the following;

  • The appearance of the patient
  • Medical history of the patient
  • Patient’s current medical condition

It also has information about a certain person involving your observations and your opinions depending on those observations. For example, after conducting nursing assessments and tests, many nurses make nursing progress notes.

Generally, these notes give details related to a patient’s overall medical status. These notes also assist you in keeping a record of your observations about patients. Along with your work, you should also include the behaviors and activities of your patient in your notes.

The details given by your notes assist you in monitoring any changes in a patient’s behavior and condition over a particular period of time. This way, you can determine what causes these changes.

What to include in a nursing note?

Nursing notes have pages along with the lines. They have title like “Progress Notes” or “Nursing Notes.” However, this document includes the following;

  • The time and date
  • The name of the patient
  • Name of the attending nurse
  • The reason for the patient’s visit
  • The vital signs of the patient
  • Your initial assessment of the patient
  • Any diagnostics or labs requested
  • An assessment of any medical interventions conducted
  • Any significant instructions provided
  • The family interactions that the patient has in the past
  • Observations and recommendations
  • Anything unusual that you have noticed

The most important information that you must include:

There are three main issues that you must mention each time you write these notes;

Description

In the description, explain what’s going on with your patient. Explain the patient’s condition in detail. Specify what you see, hear, smell, and felt as well as the remarks of the doctor.

Action

The actions that you or the doctor has taken in response to the patient’s condition explain them. This usually involves giving medication, making sure the patient’s safety, and the like.

Response

Here, provide an explanation of how the patient responded to the actions taken. In this way, you identifies either the patient improves because of your actions or your actions have no effect.

How to write a nursing note?

Nurse notes templates commonly include the following;

  • Exact nursing evaluations or documentation
  • In the condition of a patient, observed changes
  • Care or treatment provided to the patient
  • To support the clinical team, other related information

Consider the following tips to make the best nursing progress notes;

Maintain consistency

The record begins with the ID information of the patient. Each entry should include the following;

  • Complete name of the patient
  • The time
  • The date

Write down timely information

Within 24 hours of supervising your patient, you should write down your notes. This indicates that you have already completed the notes for the next nurse whom shift is next.

Use legible handwriting

The notes should be written neatly and clearly. Since these notes are made for quick reading so you should not writing down lengthy details.

Document all of your communications

Keep in mind that you have to write everything significant concerning the health of the patient. All the conversations that you have with the doctors, family members, and any other medical professional should be included in it.

Avoid using abbreviations

Don’t use abbreviations because they might mean different things to different people. Also, this may lead to miscommunications.

Write as you go

It is the responsibility of the nurse to complete all of their notes as soon as possible. You don’t have to leave your notes until the end of your shift. You may also see Nursing Resignation Letter.

Conclusion:

In conclusion, a nursing note template is an effective tool for the nurses to write down their observations about the patients. These notes have a patient’s general and basic information. They also give a complete picture of the patient’s health.

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