The Language of Nursing Notes
Between vitals, assessments, medications and other treatments, nurses have a lot of information they are required to take note of, and when working at a fast pace, it can be difficult to write everything down. Over time, nurses have been able to reduce the amount of time and effort that goes into note-taking by using abbreviations and mnemonics. These tricks help nurses quickly take patient care notes while still ensuring accurate and comprehensive documentation.
Nursing shorthand has become almost a language of its own that requires study and practice to master. Like languages, nursing notes have also developed “dialects,” varying from region to region, or in this case, health care facility to health care facility. In this article, we compiled lists of common abbreviations and their meanings as well as tips and mnemonics for taking the best nursing notes.
Nurses have developed their own unique abbreviations that serve their professional needs. Because there are no standard or approved lists of abbreviations, context is essential to understanding their use in different settings. Abbreviations and their meanings will be defined by each health care facility and its staff, and sometimes they will be quite different from those at another.
All abbreviations and definitions were sourced through Merriam-Webster’s Medical Dictionary.
|ad lib||As desired|
|hs||Hour of sleep, bedtime|
A mnemonic is a method used for recalling complex sets of information. Because many nursing routines are both complicated and exact, nurses often use mnemonics to ensure that they are ticking all the necessary checkboxes.
One of the primary responsibilities of a nurse is to complete patient charts, which explain why patients are seeking care, what their conditions are and how interventions will be made. Although charts are one of the most routine documents that nurses complete, the details contained therein must be thorough and precise. To successfully achieve this balance, many nurses use the mnemonic “SOAP” to identify the necessary information:
- Subjective data: Information provided by patient or family
- Objective data: Observable signs, symptoms, vitals and lab tests
- Assessment data: Diagnosis based on subjective and objective data
- Plan: Strategy for treatment, including short- and long-term measures
Of course, “SOAP” should be used as a framework for detailed notes to ensure no category is overlooked. Each letter should be explored further to ensure accurate note-taking. Some ways to expand on “SOAP” include:
Identifying the real issue: The impulse to run with the patient’s first complaint in the subjective section is natural, but nurses should be sure to drill in further to discover what’s at the heart of the problem.
Being brief: “SOAP” notes should be both comprehensive and concise, so nurses should leave out extraneous details and opinions.
Refusing assumptions: Nurses should not assume that their notes will only be read by doctors or fellow nurses, as lawyers, insurance company employees and others may also use them.
Keeping reimbursement in mind: Nurses should remember that their assessments may be used to determine insurance reimbursements, and thus should always connect diagnosis with intervention.
Double-checking work: Nurses should resist the temptation to run on autopilot by reviewing their “SOAP” notes for typos, inconsistencies or other overlooked details.
Besides documenting the current conditions of patients, nurses should routinely take personal health histories. A complete yet brief history often requires that the patient be prompted by questions. To recall the pertinent subjects to ask about, many nurses turn to the mnemonic “SAMPLE”:
- Past medical history
- Last oral intake
- Events leading up to the illness or injury
Because genetics play such a pivotal role in health, nurses are often required to collect patients’ family health histories. Because recalling all the ailments of relatives may be difficult for many patients, nurses have developed “BALD CHASM.” This handy mnemonic helps nurses question patients about some of the most common conditions that can be passed down:
- Blood pressure
- Lung disease
- Heart disease
- Mental health disorder
5 Note-Taking Tips for Nurses
Beyond abbreviations and mnemonics, there are tactics that nurses often employ to ensure that their note-taking is not only quick, but thorough. The ideal efficiency is obtained through a variety of means, though different contexts will demand different applications.
Whether completing a chart, writing notes for a colleague or filling out insurance forms, there are a few things that nurses should always keep in mind:
- Standardize notes: Consistently using the same abbreviations and mnemonics will not only improve note-taking efficiency over time, it will ensure legibility for others.
- Take notes immediately: While some situations demand a nurse’s full attention, taking notes too late after the fact may introduce omissions and errors.
- Avoid slang and jargon: It’s tempting to use the words that immediately come to mind, but slang and jargon are not universally understood — and therefore are best avoided.
- Only note what’s relevant: Efficiency means not transcribing every single detail, but focusing on the facts, events, observations and other information that are relevant to the case at hand.
- Date and sign everything: Who wrote something and when they wrote it are just as important as what they wrote, especially with time-sensitive subjects like medication.
Avoiding Shortcuts in Notation
Shorthand is not synonymous with shortcut, and nurses should take great care when writing notes on patients to include as many details as possible. These notes are vital for ensuring the utmost care is delivered to patients. Notes that are illegible or missing important details, such as dosages or times, can lead to allegations of malpractice.
According to an article published in Caring for the Ages, comprehensive notes should outline the nurse’s critical thinking process during the care of a patient and include: “1) assessment of a resident’s conditions, causative factors, and/or risk factors; 2) analysis of potential outcomes or consequences; 3) a plan of action; and 4) evaluation of the resident’s response to the plan.”
This care should also extend to the amount and type of abbreviations used throughout the notes. Misinterpreted abbreviations, symbols and dose designations may lead to harmful medical errors and long-term effects for the patient, nurse, and the health care facility involved. Thus, some abbreviations are best avoided and should be fully written out instead.
|Abbreviation||Should be written out as|
|cc||“Carbon copy” or “milliliters”|
|D/C||“Discharge” or “discontinue”|
|µg||“Microgram” or “mcg”|
|Q.D.||“Daily” or “Q day”|
|Q.O.D.||“Every other day”|
Additionally, zeros should always be used before decimal points but not before whole numbers (e.g., 0.1, 1, 1.1).
Note-taking is one of the essential responsibilities of a nurse that can be learned on the job, but many of the other skills that make a great nurse require formal education. To take your career to the next level and improve the quality of your care, consider the online RN-BSN from Notre Dame College. Our program is designed with working nurses in mind, and the flexible online format means you can earn your degree while balancing work.
If nursing education and instruction is a passion of yours, our online M.S. in Nursing Education program will build off your experience in clinical care. Our classes are taught by faculty with experience in the field, and our online format means you can engage with those professors and complete coursework when it’s convenient for you.