How to write in a patient's notes
For nursing students, writing in a patient's notes can feel daunting. Third-year nursing student Georgina O'Reilly-Foley passes on what she has learned about how to write clear and concise patient notes
Writing in patients' notes is one of the most important jobs a nurse carries out. This is integral to providing compassionate, safe care as it communicates how the patient has been throughout the shift, what care they have received and any changes that may have occurred to their care plan.
Patient notes are the most reliable reference about a patient's progress. It is vital that they are detailed and legible because once that staff member leaves the ward, they may not be back again for a while.
When I started my training, my mentor sat me down and taught me how to write in a patient’s notes. She was thorough, neat and concise. I learned a lot from this and continue to write my notes in the same way.
This has resulted in positive feedback from my mentors and colleagues, because they know exactly what I have done to care for my patients. The notes also enable me to provide a detailed handover to nurses on the next shift and other members of the multidisciplinary team.
Mentors in my first year of training taught me about the Problem-Intervention-Evaluation (PIE) system for documenting nursing care. This is a great system to follow as it provides a concise record of the problem identified, the care planned and the care delivered. For example:
P - Patient's oxygen saturations dropped to 93% on air.
I - Patient given 1 litre of oxygen via nasal specs.
E - Patient's oxygen saturations increased to 96%: continue to monitor.
It is important to update patient notes throughout your shift, and make a note of any changes or additional care, such as giving blood transfusions, applying wound dressings or making referrals. And remember, write your notes the way you would want to read them: we are the next generation after all.
Top tips for writing in patients notes
- Time of care takeover: for example, 'care taken over at 7.30am'.
- How the patient felt: were they alert, drowsy, confused, in pain?
- Activities of daily living: did they carry out ADLs independently or with assistance?
- Food and fluid intake: have they been eating and drinking?
- Pressure areas: are they intact? What has been done if not?
- Mobility: have they mobilised or been repositioned in the bed?
- Invasive devices: have you checked these using the trust's assessment tool?
- Medications: have these been given? Has this been documented on the drug chart?
- Bladder: has the patient passed urine? Has output been recorded if this is indicated? Do they have a catheter in place?
- Bowels: have they been opened? What has been done if not?
- Observations: does the patient have any abnormal readings? What was done if so?
- Blood glucose: have blood sugars been carried out and recorded, if indicated?
- Pain: is the patient in pain? Has medication been given if so?
- Concerns: does the patient have any other concerns? If so, say what these are and what has been done about them.
Georgina O'Reilly-Foley is a third-year nursing student at Anglia Ruskin University