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Nursing vocabulary · Documentation

Nursing notes

Meaning in nursing, with examples

nounCore term

In nursing, nursing notes means: The written or electronic record in which nurses describe a patient's condition, the care given and any changes or events during each shift.

In Turkish: hemşire notları, hemşire gözlem formu, hemşirelik kayıtları

How it is used

Nurses write, update and read the nursing notes; entries are expected to be factual, clear, timed, dated and signed. The patient's whole record is 'the notes' in the UK and 'the chart' in the US. With electronic records you will also hear 'on the system' or 'in the EPR' (electronic patient record).

Example sentences

  1. According to the nursing notes, he refused his dinner and was very sleepy.

  2. Write in the nursing notes that his daughter was updated by phone.

Common collocations

  • write in the nursing notes
  • nursing notes entry
  • read the nursing notes
  • update the nursing notes
  • chartTo write down information about a patient, such as observations, medicines given or fluids taken, in their record or on a special form.
  • care planA written plan that sets out a patient's nursing needs, the goals of care and the actions the team will take to meet them.
  • handoverThe passing of information and responsibility for patients from one nurse or team to the next, usually at the change of shift.
  • confidentialityThe duty to keep information about patients private and to share it only with people who need it for their care or have a legal right to it.

More terms: Documentation

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This page explains English vocabulary for learners. It is not medical advice.