The nursing note or also called nursing sheet, is a written record of the various observations made by a nurse about the care of a patient, whether in his physical, mental and emotional state as well as the evolution of his symptoms, the care given, medications (dose and times of the same), medical orders, treatment plan care and general evolution of the patient. These nursing notes or sheets are an integral part of the patient’s medical record, which is why they are added to it (regardless of whether they occur within a private or public medical institution).
In general, the nursing notes are a record in which various medical actions are documented that increase in a patient from his admission, including treatments, medications, and the General evolution of the patient, until his discharge or exit (his discharge), or in his case his death. It is a document that is usually added to a patient’s medical history, it is carried out by the nurse in charge of patient care, noting in it data such as the following:
- care
- administered drugs
- medical orders
- Care plans
- patient evolution
- Surgical interventions and other medical procedures
- Therapies (and their schedules)
- Complications (if any) are noted
- Feeding schedules (and, where appropriate, the type of feeding given)
And various general and particular observations about the patient (his reaction to a medication, wording of a food, whether he is a thirteenth grader not eating, his state of mind, etc.).
It is important to note that this type of document, given its importance, must be correctly filled out in terms of the data (which must be precise and concise), so the nurse must pay close attention to detail during its preparation.
In this article, you will find:
Nursing note format:
These nursing notes or sheets are usually filled out daily (to observe the evolution of the patient), to give a reliable follow-up to all the changes (advances or setbacks) in the patient’s health. These notes are delivered to the doctor or, as the case may be, to the administrative staff of a hospital or clinic, so that they make the necessary observations for the good care of the patient, as well as to be attached to the patient’s medical history.
Nursing note example:
NURSING NOTE
Name of patient: Juan Perez Lopez Age: 50 years Proceedings: 3489-45
Service: Emergencies, stabilization Bed: #5
DATE
OBSERVATIONS
01/7/20017 4:20 AM A male patient with symptoms of hyperglycemia (300 blood glucose) is admitted, 12 units of insulin are administered, as well as symptoms of dehydration, and intravenous fluid is placed. 6:00 AM The patient and blood sugar levels (220 blood sugar) are checked. 7:00 AM The patient is given breakfast, and medication is administered. 10:00 A.M. The patient is checked by taking his temperature and heart rate (it seems stable). 2:00 PM The patient is fed and blood glucose levels (180 sugar) are measured. 3:00 PM Medication is administered to the patient 4:00 PM Check-up of the patient (he says he feels better), normal temperature, no sweating. He continues to be given medication through the IV. 5:00 PM The patient is injected with 10 units of insulin. 7:00 PM Dinner is served to the patient 8:00 PM Blood sugar levels are measured (140), the patient begins to stabilize. 10: PM Check-up of the patient, medication is administered and blood sugar levels are checked, as well as intravenous flow is monitored (medications are administered intravenously). 10:20 PM The patient falls asleep, apparently stable.
Nursing note download format:
Click on the image to download the nursing note:
Cite in APA format:
Del Moral, M. (2023, January 11). Nursing Note Examples. . /examples-of-nursing-note/