Nursing notes document assessments, vital signs, interventions performed, patient statements, and responses to treatment. In inpatient and long-term care settings they are recorded per shift or per event.
They are typically the most frequent entries in a chart.
Alternative Names:
Nurse's Note, Shift Note
Why it Matters?
Nursing notes are the highest-frequency documentation in any chart, which makes them the best source for reconstructing what actually happened hour by hour. They also capture patient statements verbatim more often than physician notes, and those statements frequently differ from litigation accounts. In long-term care cases the presence or absence of documented repositioning and monitoring is the case itself.
Frequently Confused with
Related terms
Frequently asked questions
Why are nursing notes valuable in review?
What role do they play in long-term care cases?
