Sample Nurses Note

Sample Nurse’s Note

Nurses usually record every interaction they have with patients. The nurse often uses a sample nurse’s note to record various activities about the patient’s condition.

In a hospital or health center, there must be a doctor and a patient. The doctors are in charge of examining patients. While nurses tasked with recording various patient conditions based on examinations performed by doctors. Nurses generally use the sample nurse’s note to record the multiple diseases of the patient to help the team of doctors examine the patient.

Definition of Sample Nurse’s Note

Sample Nurse’s Note is a medical record created by a nurse that shows accurate documentation about nursing assessments, and changes in the patient’s condition. Besides, nurses tasked with caring for patients and recording various health information to support the team of doctors when examining patients. Here is information about sample nurse’s note

Tips on using the Nurse’s Note Sample used by the nurse.

Here are some tips for nurses using sample nurse’s note:

  • Objectivity

Write down what you see, hear, and feel. During the patient examination process


  • Clear and accurate writing

Write clear and precise information about the patient’s condition. So that patients and the medical team can understand what you write.


  • The right dose

Give the patient the right dosage according to the doctor’s permission, so there is no mistake


  • Know the language of health

Make sure you know the language of health, in support of your obligations as a nurse


  • Understand how to use a charting system

Understand the charting policy in knowing medical facilities and the use of electronic medical record systems


Format about Sample Nurse’s Note.

The following are some types of formats about sample nurse’s notes:

  • Nurse Notes 1A

Data that has reviewed through the primary data assessment format grouped into subjective data (DS) and objective data (DO)


  • Nurse Notes 1B

It contains data analysis and identifies client ethics and problems.


  • Nurse Notes 2

It includes a problem/nursing diagnosis, the date the problem found, and the client’s problem is topped.


  • Nurse Notes 3

It includes a nursing plan consisting of; day and date/hour, nursing diagnoses accompanied by supporting data, objectives to be achieved, plan of action, and rationalism.


  • Nurse Notes 4

It contains nurses’ actions and the results obtained.


  • Nurse Notes 5

It includes patient development records consisting of days, dates, diagnosis numbers, hours/time, SOAP data (Subjective, Objective, Assessment, Planning).


  • Nurse Notes 6

Contains the final resume or re-patient summary


Benefits of Using Sample Nurse’s Note.

Here are some benefits of using a sample nurses note:

  • Provides information about the overall status of the patient’s medical records
  • Assist nurses in recording observations about patients
  • Monitor changes in the patient’s condition and behavior over some time
  • Assist in concluding examination results
  • Remind nurses or medical practitioners about the patient’s condition


The existence of a Nurse’s Note Sample as a recording process in making decisions is included assessment, problem identification, planning, and action. So that patients can be treated immediately and get maximum medical care.



sample nurses note

sample nurses note

sample nurses note

sample nurses note

sample nurses note

sample nurses note

sample nurses note

sample nurses note

sample nurses note

sample nurses note

sample nurses note

sample nurses note

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