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How to write in Nursing Notes

The famous nursing proverb is; ‘If it’s not written down; it didn’t happen…’

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The Nursing and Midwifery Council (NMC) Code of Conduct states that we all must “keep clear and accurate records”.

Documentation and record-keeping featuring is a prominent feature in within the NMC Code of Conduct. It is your duty as a nurse or midwife to keep your notes up to date, not only to protect your patients, but also to stay on the right side of the law.

Substandard record-keeping is one of the top five reasons for nurses being removed from the NMC register. You should consider your nursing notes as evidence of the care you have provided and will act as a reminder in the event of a complaint or investigation.

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The famous nursing proverb is; ‘If it’s not written down; it didn’t happen…

Here are a few core guidelines you should keep in mind when you write notes on any patient:

Write as you go. The NMC says you should complete all records at the time or as soon as possible. Try to avoid leaving your nursing notes to the end of the shift – write as you go. This will ensure everything you document is fresh in your mind and therefore accurate and up-to-date.

Use a systematic approach. Try to use a systematic approach to documentation; ACBDE, SBAR etc – this will help ensure your notes are both detailed and accurate. A good method is to; describe what happened, provide your clinical/nursing assessment and finally explain what you did about the situation.

Keep it simple. Nursing notes are designed to be quickly read, so the next shift can be caught up to speed on a patient.

Try to be concise. Writing a few lines can sometimes provide more information than writing a whole page.

Summarise. Don’t duplicate. If you have already documented a full assessment in other nursing documentation you can summarise this rather than duplicating it – you’re just creating yourself more work.

Remain objective and try to avoid speculation. Write down only what you see, hear and do. Try to avoid speculative comments unless they are relevant to patient care such as consideration to future care.

Write down all communication. Any discussions you have had with family, doctors or other healthcare professionals should be documented in the nursing notes. You should also document the names of people involved in discussions.

Try to avoid abbreviations. Write out complete terms whenever possible. An abbreviation can mean different things in different areas. Your trust should have a pre-approved abbreviation list.

Consider the use of a scribe. Emergency events such as cardiac arrests, trauma calls or medical emergencies commonly have poor documentation. Consider appointing a member of staff to write things down as you go; times and doses of medications, medical reviews, clinical interventions etc.

Write legibly. If nobody can read your notes there isn’t much point in writing them at all.

Finally, you should ensure your documentation is clearly signed and dated. Student Nurses or un-registered staff may need to have their documentation countersigned – you should check your local trust policy.

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Former student nurses share their top money-saving tips

“A nursing degree is very different to most undergraduate courses.”

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Student money saving tips

Direct from former student nurses, the Student Money Guide is packed with useful tips.

New nursing students should claim fuel reimbursements, car share, compare markets and supermarkets and seek second-hand textbooks to make their student funding, and part-time wages go as far as possible, updated advice from the Royal College of Nursing (RCN) says.

The College’s latest Student Money Guide for nursing is packed with useful information on childcare, travel expenses, charitable funding and tips for those moving into private rented accommodation.

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The top money-saving tips.

Direct from former student nurses, the guide offers some top money-saving tips, which include;

  1. Develop a good relationship with your bank – meet and go through all the options and accounts which will save you most money and give you the best interest rates
  2. Use online materials, the RCN Library for example, instead of buying textbooks – If you do buy them, try advertising on university notice boards for second-hand copies, or, have a look at www.abebooks.co.uk. Use cashback websites, such as Quidco, when making purchases.
  3. Get a Young Persons Rail Card if you spend over £72 a year on rail travel – all full-time students are eligible, regardless of age.
  4. Claim fuel reimbursement if you drive further to placement than to university – it is offered, so you might as well.
  5. Be penny-wise, seek out free pickings – go to sites like Freecycle for free furniture, kitchenware and bicycles.
  6. Check out your local discount warehouses for basics, cleaning products, toilet rolls, washing powder and buy these as a household to split the cost of a bulk buy – it is well worth it.
  7. Share lifts to placement and do food shops with fellow students.
  8. Make sure your supermarket shop is cheapest – check online comparison sites like mysupermarket.com ahead of your shop.
  9. Use your local butchers and market.
  10. Take a packed lunch and flask to university – you will save a small fortune and probably eat better.

Nursing is different to other degree courses.

Claire Cannings, Senior Welfare Adviser commented: “A nursing degree is very different to most undergraduate courses. The placement element means there is less time for part-time work, and the long shifts mean childcare and travel is often more expensive.

“Fluency with finances, brilliance with budgeting and keeping clued-up on things complimentary can pay dividends. This can, in turn, impact positively on study and well-being through a student’s learning years and beyond. It’s amazing how many grants and funds students are entirely unaware of which is why we’ve collated all the information they need in one place.

“While the RCN will still be making the case to Government to invest in nursing education, we hope the guide will continue to be a valuable resource to our current and potential members.”

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Clinical Updates

Induction framework for General Practice Nurses launched

It also provides guidance for practices employing General Practice Nurses.

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The document provides a framework for both new and experienced general practice nurses.

NHS England, in collaboration with The QNI, has launched a new Induction Template for General Practice Nursing.

The Induction Template is has been designed to enable employers to ensure that nurses in a first career destination role in General Practice are well supported when taking their first career step in primary care.

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Not just useful for newly qualified nurses, the 51-page document provides an induction framework for all new general practice nurses, enabling them to develop key skills required for the role.

It also provides guidance for practices employing General Practice Nurses.

Nursing associates, health care assistants and student nurses preparing for a primary care placement may also find the template useful.

A great start to a long and exciting career’.

The author of the document, Queen’s Nurse and experienced nursing mentor and educator, Sharon Aldridge-Bent said; “Developing this template highlighted the urgent need for a comprehensive induction and orientation programme for all nurses new to general practice.

“This most certainly will assist with recruitment and retention of nurses in the primary care setting.”

Paul Vaughan, Head of Nursing Now England, responsible for the delivery of the GPN Ten Point Plan, said: “this new resource will enable employers to ensure they provide nurses new to general practice with a really good experience of working in the sector and ensure they have a great start to their long and exciting career working general practice.”

The resource underpinned by General Practice – developing confidence, capability and capacity – A ten-point action plan for General Practice Nursing (2017) contributes towards the overall strategic goals outlined in the General Practice Five Year Forward View.

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