I’ve seen comments on this and other subreddits from doctors who say they don’t bother to read nurses shift notes because they are full of fluff. Stuff like bedrails up, will continue to monitor, etc. I also find those notes pretty useless and frustrating. As a night shift nurse, I try to make my notes useful and hope they will be read as I often don’t have a direct way to communicate with the primary team (telling a day shift nurse about an issue has maybe a 50% chance of actually being addressed with the doctor). So I’m wondering what do you want to see in our notes? What information is useful to you? Are my notes too long/too much information? What else should be included?
Right now, I try to write my notes with a basic formula which includes three main points:
A brief assessment of major body systems (cognitive, cardiac, pulmonary, GI, GU, skin/wounds, mobility)
Any PRNs given and if they were effective or not
Any acute issues/events and how they were addressed
So a note on, for example, a post-op CABG might read like this:
Pt is alert and oriented. Sternal pain well controlled with oxycodone given twice. He had one brief episode of A fib but converted back to sinus rhythm after 15 minutes. BP has been stable. Oxygen weaned from 4 to 2 liters and he states SOB is improving. Voiding adequate clear yellow urine. No BM since surgery, PRN miralax given. Sternal incision and chest tube sites are well approximated with scant serosanguinous drainage. He is ambulating 360 feet independently with no symptoms.
A note on a CHF exacerbation might read:
Pt was alert and oriented at start of shift with new onset confusion around 2200, along with increased dyspnea. MD notified and order obtained for CXR, 80mg lasix, and ABG. ABG showed hypoxia and Pt started on bipap. Dyspnea and mental status improved with diuresing and bipap. She remains in sinus rhythm/sinus tach, HR 90-110. Foley remains with large amount of output. She had one BM this shift, no GI symptoms. No skin breakdown noted. She requires two person assist for bed mobility and transfer to bedside commode.
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