What do nursing notes typically include?

Nursing notes are an essential aspect of patient care documentation, providing detailed information about a patient's condition over time. The inclusion of vital statistics, which comprise measurements such as heart rate, blood pressure, temperature, and respiratory rate taken at regular intervals, is a critical component of these notes. These statistics reflect the patient's clinical status and help track changes in their health condition, guiding nursing interventions and medical decisions.

While patient discharge information, diagnosis summaries, and psychiatric evaluations are also important in the overall scope of patient care, they are not typically found in nursing notes in the same consistent and ongoing manner as vital statistics. Instead, those elements are usually contained in discharge summaries, diagnostic records, or specific psychiatric assessments, serving different documentation purposes in patient management. Thus, the presence of vital statistics in nursing notes is fundamental to continuously monitoring and responding to a patient’s health needs.