Nursing documentation: How to

write a patient's notes

Writing a patient's notes is one of the primary responsibilities within the nursing profession. At the
start, it can be daunting. However, it's integral to delivering top-quality care.

Regardless of the form of the records (i.e. electronic or paper), good clinical record keeping should
enable continuity of care and should enhance communication between different healthcare
professionals. Here are some tips on how to write concise patient notes.

Ensure your writing is clear and legible

Illegible handwriting can lead to a patient receiving the wrong medication or an incorrect dosage of the
right medication. This can have serious, or even fatal, consequences. Keep your writing as neat as
possible and use a pen that produces clean lines and doesn’t smudge.

Note all communication

Jot down everything important you hear regarding a patient's health during conversations with family
members, doctors and other nurses. This will ensure all available information on the patient has been
charted. Always designate communication with quotation marks as this makes your notes as clear as
possible.

Write as often as you can

Write your notes within 24 hours after supervising the patient's care. Writing down your observations
and noting care given must be done while it is fresh in your memory, so no faulty information is
passed along. Writing notes within this time is a very good habit to get into as a nurse as you’ll find
that it starts coming naturally over time.

Try the PIE format

PIE stands for problem, intervention and evaluation. Writing in this format allows your colleagues to
see what steps you've taken to resolve any problems.

e.g. Problem: Patient's oxygen levels dropped. Intervention: Patient was given one litre of oxygen via
nasal specs. Evaluation: Patient's oxygen saturations increased - continue to monitor.

Know what sort of things to record

A lot can happen during your time with a patient, so it can be tricky to decide what needs to be
included in their notes. Here are some examples of what you should be recording:
  Care takeover
 How the patient is feeling - alert, drowsy, confused etc
 Mobility
 Blood glucose
 Concerns
 Medications
 Food and fluid intake
 Bladder
 Bowels
 Pain

GROUP 2: Purposive Communication

Chapter 4: Communication for Work Purposes

Lesson 1: Communication for Nurses: Writing Basic Patient Notes

10 Nurse Communication Skills for Success

1. Non-Verbal Communication
You can communicate a powerful message without saying a word. Non-verbal nurse communication
skills include making eye contact and controlling the tone of your voice. Appropriate body language,
posture, and simply adding a smile can go a long way in nurse communication with both patients and
colleagues.
2. Active Listening
 Listen to understand; not solely to respond—this is one of the best principles for active listening.
When speaking to a colleague or patient, lean forward and nod your head to let them know you are
engaged. Maintain eye contact.
 Carry your body in a relaxed posture; do not cross your arms
3. Personal Relationships
With practice, you can learn to show care, compassion, and kindness while obtaining and providing
information to patients. You must be able to demonstrate a level of interest in the collaborative
relationship. This will help the patient feel accepted and build their trust in you.
4. Inspire Trust
Always keep your word. Never make promises you may not be able to keep. When you are with a
patient, be present. Listen to your patients and take all their complaints or concerns seriously.
5. Show Compassion
 Treat patients with respect and dignity. Being in the hospital can be scary.
Patients may feel depressed, helpless or even frightened. Put yourself in the shoes of your patient.
Doing so will help you convey empathy while using your nurse communication skills.
6. Cultural Awareness
 Every patient is unique. They may come from different countries, cultures or religions.
Common practices and gestures are not accepted by all cultures. Consider your actions and strive for
cultural awareness every time you communicate with a patient.
7. Educating Patients
This nurse communication skill is at the heart of nursing. You must be able to explain disease
processes, medications, and self-care techniques to patients and their families.
teach-back Break down medical jargon into simple terms. Education should be collaborative. Ask
patients questions and use techniques when possible.
8. Written Communication
This is essential for nurse-to-nurse communication. Always ensure your written communication is
concise and easy to understand.
Write in complete sentences that are grammatically correct. Only use approved abbreviations and
terminology that is universal.
9. Presentation Skills
Nurses in leadership positions are not the only ones who need this skill. You may be asked to present
to nurses or other staff members on a small or large scale.
Plan your message. Create pleasing visual aids that add value to the presentation. Know your audience
and understand what they want from your presentation.
10. Verbal Communication
Verbal nurse communication skills are of the utmost importance. Always consider your audience.
Speak in clear, complete sentences and consider your tone when speaking.
Nurse communication skills are indispensable to your success as a nurse, and with practice, you can
become a nurse communication expert!

https://www.studocu.com/ph/document/holy-trinity-college-of-general-santos-city/purposive-
communication/purposive-communication/9048139

Why do we need good notes for patients?

Why do I need to keep good records? Good clinical notes document the medical history of
the patient. By documenting all relevant clinical information you are recording this information
for future reference. Remember, if you did not write it down, it did not happen