NURSES NOTES

INTRODUCTION:

Nurses note are important documentation where the nurses entirely assess and documents. There are
various documents maintained by the nurses entirely while taking care of the patients admitted in the
hospital. The entire documentation process regarding the patient health status is done by the nurse
allocated for the specific patient.

The following are the nurses notes/documents maintained by the nurses

1. Assessment sheet: this includes detail head to toe assessment of the patient which is done on
every shift by the nurse. Assessment of the presence and patency of cannulation type, drainage
catheter, urinary catheter, urinary catheter, stoma and feeding tubes is also included in this
portion.
2. Vital signs, Intake and Output monitoring chart: Here the vital signs monitored, the amount of
intake either orally or intravenously, the output in the form of urine, vomit, stool, drain amount,
naso-gastric aspiration is recorded. Also any procedure done such as bone marrow aspirate,
central line dressing, Intra- thecal injection, investigations sent or any special instruction to
follow as recommended by the physicians.
3. Nursing Process: In this section, the problems of the patients are identified and the suitable
nursing diagnoses are selected for which the interventions required are followed with
evaluation to be done at the end of the shift.
4. Graphic T.P.R chart: This shows the graphical presentation of the vital signs monitored, blood
pressure, temperature, pulse and respiration in order to easily detect any deviation from the
normal for which prompt action can be taken.
5. ICU investigation trend chart: this chart is used by the nurses to record the results of the
laboratory investigations carried out.
6. Infection Prevention and Control bundle: this sheet includes a few steps to follow daily in order
to prevent any kind of infection from the presence of central line, catheter, patient on
ventilation and patient with surgical incision. It includes the following bundle:
 Catheter associated urinary tract infection (CAUTI)
 Central line associated blood stream infection (CLABSI)
 Ventilator associated pneumonia (VAP)
 Surgical site infection (SSI)
7. Charge sheet: in this sheet the allocated nurse will record the time and frequency of any
procedure like CBG monitoring, Nebulisation, Oxygen monitoring, Urine ph monitoring, and
patients on ventilator support which is then checked and counter sign by the customer care.
8. Chemotherapy record: this includes recording the details of patient such as the weight, height,
BSA, any allergies, diagnosis and cycle of chemotherapy. This record also includes a section of
chemotherapy order flowchart where the chemotherapeutic drug details such as the name, dose,
IV fluid used for dilution, amount, duration, route, start time, end time, the date and day of
chemotherapy along with the nurses’ signature is documented.
9. Pre- operative records: this includes pre-operative instruction sheet, pre-operative teaching and
pre-operative checklists.
 Pre-operative instruction sheet: this includes all the patient’s details, start time of NPO,
microshield bath, pre-operative medications which are due, marking the site of surgery and
special instructions such as any investigations to be carried out before surgery, any blood
units needed to be reserved.
  Pre-operative teaching: in the pre-operative teaching the patient is explained about the
anatomy and physiology of organs, pre-operative procedures to be followed, the
environment the patient will experience in the operation theatre, anaesthesia, operative
events, transfer to ward and visit to ICU in case of any complications.
10. Pre- operative checklists: includes the duty of the allocated nurse to check and verify if the
preparation of patient and required documents has been completed or not such as pre-
anaesthesia check up, patient’s consent, microshield bath, NPO status, pre- operative
medications, cannulation type, vital signs, securing of loose teeth, removal of dentures, nail
polish, contact lens, and all the investigations such as ryle’s tube, tracheostomy tube is present
or not along with the record of vital signs and capillary blood sugar monitored.
11. Clinical observation for flap failure: this includes a daily assessment of the viability of the flap
in terms of colour, temperature, texture and capillary refill which is monitored by the nurse
either hourly or as per the physicain’s orders.
12. Checklists: includes the following:
 Pre- operative checklists
 Checklist for transfer out
 Checklist for patient discharge

The above nurse’s notes are required to be written and recorded in a clear and concise
statement along with accurate follow- up and recommendations as per the primary team.