The art of crafting effective nursing notes is a crucial aspect of healthcare documentation. These notes serve as a comprehensive record of a patient’s medical history, treatment, and progress, facilitating seamless communication among healthcare providers. Here are five examples of nursing notes, each highlighting different aspects of patient care and the diversity of scenarios that nurses encounter:
Example 1: Admission Note
Patient Name: Emily Wilson
Date: 2023-02-15
Time: 08:00 AM
Reason for Admission: Emily Wilson, a 65-year-old female, was admitted to the hospital due to symptoms of acute respiratory distress. She presented with a history of coughing, fever, and difficulty breathing.
Vital Signs:
- Temperature: 38.5°C
- Blood Pressure: 140⁄90 mmHg
- Pulse: 110 beats per minute
- Oxygen Saturation: 88% on room air
Assessment: The patient appears distressed, using accessory muscles for breathing. Lung sounds reveal bilateral wheezes and crackles. She is alert and oriented but reports a severe shortness of breath.
Plan:
1. Administer oxygen as prescribed (2L via nasal cannula).
2. Initiate antibiotic therapy as ordered by the physician.
3. Monitor vital signs closely, especially oxygen saturation and respiratory rate.
4. Educate the patient on deep breathing exercises to improve lung expansion.
Example 2: Medication Administration Note
Patient Name: David Lee
Date: 2023-02-16
Time: 10:00 AM
Medication Administered: Aspirin 81mg, orally, for prevention of myocardial infarction.
Dose and Route: One tablet, swallowed with 8oz of water.
Response: The patient tolerated the medication without immediate adverse effects. He was advised to report any symptoms of heartburn or gastrointestinal discomfort.
Follow-Up: Monitor for signs of bleeding or bruising, given the anticoagulant properties of aspirin. Next dose scheduled for the same time tomorrow.
Example 3: Progress Note
Patient Name: Sarah Taylor
Date: 2023-02-17
Time: 14:00 PM
Subjective: Sarah reports feeling better today, with decreased pain in her left leg post-surgery. She rates her pain as 4⁄10, down from 7⁄10 yesterday.
Objective:
- Vital signs are stable (BP 120⁄80 mmHg, Pulse 80 bpm).
- The surgical site appears clean and dry, without signs of infection.
- She is able to bear weight on the affected leg with minimal assistance.
Assessment: The patient is showing positive signs of recovery. Pain management is effective, and there are no immediate concerns for infection or other complications.
Plan: Continue with current pain management regimen. Increase physical therapy sessions to twice a day to enhance mobility and strength.
Example 4: Transfer Note
Patient Name: Michael Davis
Date: 2023-02-18
Time: 09:00 AM
Transfer Details: Transferring Michael Davis from the ICU to the general medical floor due to stabilization of his condition.
Current Status:
- Vital signs are stable (Temperature 36.8°C, BP 125⁄85 mmHg, Pulse 90 bpm).
- Oxygen saturation is 95% on room air.
- He is alert and oriented, able to perform daily activities with minimal assistance.
Report Given to Receiving Nurse: The patient requires regular monitoring and continued antibiotic therapy. He has a history of diabetes and hypertension, which should be managed according to his current regimen.
Example 5: Discharge Note
Patient Name: Olivia Martin
Date: 2023-02-19
Time: 11:00 AM
Discharge Summary: Olivia Martin is being discharged home today after a successful recovery from pneumonia. Her vital signs are stable, and she has shown significant improvement in respiratory symptoms.
Instructions:
1. Continue antibiotic therapy as prescribed for the full course.
2. Follow up with her primary care physician in one week.
3. Monitor for signs of respiratory distress and seek immediate medical attention if symptoms worsen.
Patient Education: Educated on proper medication use, signs of infection, and the importance of follow-up appointments. The patient demonstrates understanding and is capable of self-care.
These nursing note examples demonstrate the breadth of information and the level of detail required in healthcare documentation. Each note serves a specific purpose, whether it’s admitting a new patient, administering medication, tracking progress, transferring care, or discharging a patient. Effective nursing notes are indispensable for ensuring continuity of care, patient safety, and optimal outcomes.
