Nursing notes are a crucial part of the healthcare documentation process, providing a clear and concise record of a patient’s care, treatment, and progress. These notes are used by nurses, doctors, and other healthcare professionals to communicate effectively and ensure continuity of care. Here, we will explore various examples of nursing notes, including their structures, formats, and the types of information they typically contain.
SOAP Note Example
The SOAP note is one of the most commonly used formats for nursing notes. It stands for Subjective, Objective, Assessment, and Plan.
- Subjective: The patient reports feeling dizzy and experiencing some nausea after standing up too quickly.
- Objective: Blood pressure reading was 90⁄60 mmHg, and the patient’s gait was unsteady, requiring assistance to walk.
- Assessment: The patient is experiencing orthostatic hypotension, likely due to dehydration.
- Plan: Encourage the patient to drink more fluids, elevate the head of the bed by 30 degrees when standing, and provide physical support during ambulation.
Focus Charting Example
Focus charting is another method used for documenting nursing care. It involves a focus column, a data column, an action column, and a response to action column.
- Focus: Patient safety during mobility.
- Data: The patient expressed fear of falling and had an unsteady gait.
- Action: Placed a non-slip mat in the bathroom, ensured handrails were secure, and provided gait training with assistance.
- Response to Action: The patient was able to move around the room safely with minimal assistance and expressed feeling more confident.
PIE Note Example
The PIE (Problem, Intervention, Evaluation) note is a format that structures nursing documentation around the problem the patient is experiencing, the intervention provided, and the evaluation of the effectiveness of that intervention.
- Problem: Pain management for post-operative patient.
- Intervention: Administered acetaminophen 1000mg IV as prescribed and repositioned the patient every 2 hours.
- Evaluation: The patient reported a decrease in pain from 8⁄10 to 4⁄10 after intervention, indicating effective pain management.
Narrative Note Example
Narrative notes provide a more free-form format for documenting nursing care, allowing nurses to describe the patient’s condition and care in detail.
The patient, who underwent surgery yesterday, presented with significant discomfort today. The patient-rated pain was 8⁄10. After administering the prescribed pain medication and repositioning the patient, a follow-up assessment showed the patient’s pain had decreased to 4⁄10, indicating an effective response to the intervention. The patient was encouraged to continue reporting any pain to ensure optimal management.
FOCUS-PDCA Note Example
The FOCUS-PDCA framework is similar to PIE but incorporates an additional planning phase. FOCUS stands for Find, Organize, Clarify, Understand, and Select, while PDCA stands for Plan, Do, Check, and Act.
- Find: Identified a need for improved wound care for a patient with a stage 2 pressure ulcer.
- Organize: Gathered wound care supplies and reviewed current wound care protocols.
- Clarify: Discussed the patient’s condition and the importance of wound care with the patient and family.
- Understand: Assessed the patient’s understanding of the wound care plan and addressed questions.
- Select: Selected an appropriate wound dressing and developed a plan for daily wound care.
- Plan: Developed a schedule for wound inspection and dressing changes.
- Do: Implemented the wound care plan, including dressing changes and debridement as necessary.
- Check: Monitored the wound for signs of healing and infection.
- Act: Adjusted the wound care plan as necessary based on patient response and wound condition.
Each of these examples demonstrates how nursing notes can be structured to convey critical patient information clearly and efficiently. The choice of format can depend on the specific needs of the patient, the preferences of the healthcare institution, and the particular focus of the care being documented.
