What are nursing notes?
Since nurses are patient advocates and often have the most contact with their patients, their notes provide the most complete picture of the patient’s health to the other health professionals and specialists involved in their care. A nursing note is a medical note into a medical or health record made by a nurse that can provide an accurate reflection of nursing assessments, changes in patient conditions, care provided and relevant information to support the clinical team to deliver excellent care.
How important are nursing notes?
Health care providers in hospitals typically use predictive models comprised of lab results, vital signs, and physiological and demographic information to predict the 30-day survival of intensive care unit (ICU) patients. However, new research suggests that the notes of ICU nurses should be included when predicting survival rates.
Researchers at the University of Waterloo in Ontario have found that sentiments in healthcare providers’ nursing notes can be good indicators of whether intensive care unit (ICU) patients will survive.
Study on sentiment in nursing notes
For this study, which was published recently in the journal PLoS ONE, the researchers used the large publicly available intensive care unit (ICU) database, which contained patient data between 2001 and 2012. After some inclusion and exclusion criteria were considered, such as the need for at least one nursing note for a given patient, the dataset used in the analysis included details about more than 27,000 patients, as well as the nursing notes.
The researchers applied an open-source sentiment analysis algorithm to extract adjectives in the text to establish whether it is a positive, neutral or negative statement. A multiple logistic regression model was then fit to the data to show a relationship between the measured sentiment and 30-day mortality while controlling for gender, type of ICU, and simplified acute physiology score.
According to the researchers, hospitals typically use severity of illness scores to predict the 30-day survival of ICU patients. These scores include lab results, vital signs, and physiological and demographic characteristics gathered within 24 hours of admission.
“The physiological information collected in those first 24 hours of a patient’s ICU stay is really good at predicting 30-day mortality,” said Joel Dubin, an associate professor in the Department of Statistics and Actuarial Science and the School of Public Health and Health Systems. “But maybe we shouldn’t just focus on the objective components of a patient’s health status. It turns out that there is some added predictive value to including nursing notes as opposed to excluding them.”
As such, the note-sentiment analysis provided a noticeable improvement for predicting 30-day mortality in the multiple logistic regression model for this group of patients. There was also a clear difference between the patients with the most positive messages who experienced the highest survival rates and the patients with the most negative messages who experienced the lowest survival rates, the study revealed.
“Mortality is not the only outcome that nursing notes could potentially predict,” noted Dubin. “They might also be used to predict readmission, or recovery from infection while in the ICU.”
The next steps include translating the findings into assisting health care providers in making better decisions in the ICU. Possible future steps could include developing automated prediction models with the capability of identifying high-risk patients so that appropriate resources can be used to prevent adverse outcomes.
In regard to the studying of sentiment analysis in patient’s notes, the researchers indicate an area of interest could be if nurses assigned their notes a score of “negative,” “positive,” or “neutral,” to produce a “labeled corpus of nursing notes.”
When should nurses chart their notes?
Ideally, you make quick notations during your visit and add more depth immediately after you leave the patient’s room when the information is fresh and top-of-mind. American Nurse Today says making brief notes while assessing the patient will help you chart faster and give more accurate (formal) nurses’ notes right after your visit. This helps you move efficiently between each patient you need to see. Visit, chart, repeat.
How to write great nurses notes?
What should not be included in a nurse’s notes?
Lippincott Nursing Center states you should only include the facts, rather than your personal opinion. However, your opinion can be verbalized to other healthcare professionals so they can get a better picture of the patient (e.g., Social Services notified; request for one more day of stay due to patient unable to care for self at home).
Here are some other notations that cross an ethical line when putting informal/permanent notes:
- Personal information regarding the patients’ family members and friends
While it’s OK to give very generalized information on them (e.g., they visited), nothing personal should be included (e.g., they were intoxicated, unkempt, uncaring, etc.).
- Dialogues you’ve had about patients between providers
Instead of conversation details, just note that you’ve informed certain physicians.
- Anything from the ISMP list of abbreviations
These are often misinterpreted and lead to medication errors.
- Your opinion
Instead, report on your recommendations and the systems you have put in place or staff you’ve notified (e.g., this RN recommends social worker evaluate patient’s ability to obtain supplies needed at home upon discharge).
- Negativity about the staff that could be portrayed as defamatory
There should be another system for reporting staff issues within your organization. But there are ways around saying what you want to say. For example:
You want to say: “The doctor isn’t concerned about something that I’m concerned about.”
But actually say: “MD notified. No further orders.”
Watch the following video to know more about Nursing Documentation Tips!
How will nursing notes be used?
Nursing notes can be used for various purposes from assessing proper medical care to malpractice litigation. Thus it is important that nurses write their nursing notes with various audiences in mind
The Healthcare Team
Nursing notes provide a healthcare team with a complete and accurate timeline of a patient’s health status and care. This is key to determining a diagnosis and further care.
Nursing notes should be complete enough to jog a nurse’s memory if any details are not clear or hazy. In the unfortunate case that a nurse must testify for a lawsuit, clear and accurate nursing notes serve to ensure the details of a nurse’s care.
The Lawyers, Judge, and Jury
Clear, comprehensive nursing notes ensure if our judicial system can determine if a patient’s nursing care was reasonable and prudent.
“Nurses are angels in comfortable shoes.”
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