Early and frequently, nurses learn that patient care is the No. Priority one; charting comes in second. It can be difficult to strike a balance between charting and meeting your patient’s needs, but it is necessary to accurately communicate all updates to various providers. Science Direct says that high-quality care requires interdisciplinary communication, and that improving communication will ultimately help improve patient outcomes.

Consider it this way: The quality of a shift nurse, doctor, or other healthcare provider is only as good as the patient’s charting. Since nurses’ notes are an important part of this chart, they should be clear, accurate, and up to date. But how much information is too much? And how can you strike a balance between interacting with patients and writing accurate nursing notes? Throughout your nursing career, you will record a lot of information in charts and notes. You can make these assessments more thorough, helpful, and less stressful by following these tips.

What are notes from nurses?

• Because nurses are advocates for patients and frequently have the most contact with their patients, their notes provide the most comprehensive picture of the patient’s health to the other health professionals and specialists who are assisting with their care. Based on the notes and scribbles that nurses collect during a patient visit, these notes are the formal documentation that nurses create when charting. They may also incorporate charting by exception, a shorthand method for initialing lists and charts to note the patient’s “exceptions” or abnormalities.
• If a malpractice case is ever filed, these charts will be used by the involved legal team. While keeping detailed and accurate notes is crucial for maintaining effective communication between nurses and medical staff, they will not be used in any malpractice cases. The formal notes that are taken on a patient will help a nurse remember the events of the day, the care provided, and the specialists involved in the event that they are ever sued or called as a witness. This is because nurses care for multiple patients at once.

What Makes Nurses’ Notes and Charting Different?

• Charting includes the notes of nurses. They are brief notations on pre-established lists (charting by exception) that typically include a one-paragraph summary of the patient’s health throughout the visit or time period.

What Are Some Examples of Nurses’ Notes?

To provide you with a little more context, here are some good examples of nursing notes:

• “When I walked in the room, the patient was blue and having trouble breathing. I called a Code Blue and started CPR. Then Code team arrived.”
• “Lung sounds clear to auscultation bilaterally. Color pink. No signs of respiratory distress noted. VSS. Patient eating 90% of his meals and tolerating well. No abdominal distention or emesis this shift. Patient ambulating adequately. Voiding spontaneously. No BM this shift. Patient’s weight remained the same. Spouse visited patient today. Bed rails up x4. No hazards in room. Call light within reach.”

The computer chart is typically referred to when nurses discuss charting. The physical (clipboard) chart may only contain the patient’s history, whereas the computer chart contains everything that occurred during this stay because many hospitals and clinics are going paperless.