A nurse is a noble profession. There are many medical tasks that a nurse is expected to be performed after being trained. Besides assisting the doctor, a nurse is trained to care for the patient and to record the patient’s medical condition accurately so that the health of the patient improves.
A nursing note is similar to the patient’s welfare chart. Every nurse will be assigned some patients to be cared for as well as to monitor the progress. Medication intake is noted with care in a nursing note to ensure that no wrong prescription is applied. The nursing note assists the nurse in caring for her patients by recording the patient’s medical condition, even the background and medical history.
The nurse has to brief the attending physician when he comes on his round to check on her ward. The nurse must be up to date on the status of her patients to update the doctor on the latest development of her patient.
A nursing note template would contain the following information:
* Nurse’s name and status
* Ward assigned
* Patient’s Name & admission number
* Patient’s background & medical history
* Patient’s health condition
* Patient’s current diagnosis
* Patient’s treatments
* Patient’s counseling sessions
* Physician’s name
* Physician’s recommendations
* Overall progress
* Date of consultation
A nursing note can be a personal tool by the nurse or it can be a medical record requirement in the health care facility.
Consider the attached sample template for your convenience.