Appropriate and legible nursing note documentation gives a precise observation of nursing assessments, condition changes, the care that was provided, and relevant patient details in order to support integrative medical organization to provide and deliver outstanding patient care. Having a nursing note gives proof of care and is an essential medico-legal requirement of every nursing practice.
In order to provide a structured and standardized approach to nursing assessment and documentation for patients, having an effective and well-constructed nursing note is a must. For that, we’ve prepared several nursing note templates that are ready for download. These are made by professionals and are based on a real-life medical situation. Check out more of our samples below.
Psychiatric Nursing Note Template
Nursing Note in Doc
More of Our Nursing Note Templates
These are some of the nursing note templates that we offer. Take note that all of these are ready-made and are downloadable. You can also edit them if there is a need to. Select which one you think matches what you need.
- Psychiatric Nursing Note Template – This is the ideal template to use if your focus is on psychiatric patients. This contains details that are necessary in every psychiatric nursing note such as the patient’s name, the services given by the assigned nurse, observations/monitoring, patient/family teaching information, therapy provided, and so on.
- Narrative Nursing Note Template – If you’re making a narrative nursing note that indicates the conditions and progress toward care plan goals for every patient, then this template is what you need. This is also an essential note for growing emphasis on data-driven documentation.
- Nursing Progress Note Template – A type of nursing note where it provides details that show a patient’s progress and development. It’s packed with other relevant information too! So if you’re making a note of this type, why not download this template instead.
If you’re looking for a medical doctor’s note, perhaps our medical doctor note template samples are what you need.
Free Skilled Nursing
Helpful Tips When Writing a Nursing Note
A nursing note or documentation is a lasting collection of legal documents that should support an accurate report that focuses on the health condition of every patient. Nursing notes need to have sufficient data. This is to allow each nurse to provide utmost care.
- Do not document a nursing note before it is done. Every nursing staff must never take note assessments or administration of medication before it is acted upon. This may lead to an inaccurate record that contains incorrect details.
- Do not put on your nursing note that a patient is suffering. Always thoroughly note all details and interventions taken to prevent possible liability.
- Do not make offensive statements to patients while documenting. As much as possible, avoid any insulting references when writing down your nursing note. Make use of objective statements and direct quotes whenever possible.
- Do not include in your note any subjective definitions. Always have an accurate detail for a vital sign, intakes and outputs, and other information that are measurable.
These are the things you need to consider when taking a nursing note. Another sample that is closely similar to these notes is a doctors note template. Just click on the link to view image samples.