Nurses are patient advocates and often have the most direct contact with patients. Their notes provide the best picture of the patient’s condition to other specialists and health care providers. These notes are the official documentation that nurses use when charting. They are based on the notes and scribbles made by nurses during patient visits. They can also include charts by exception. This is a way to quickly note “exceptions” and abnormalities that the patient is experiencing by including charts and lists of initials.
It is critical to keep accurate and complete notes in order to maintain effective communication between nurses, medical staff and patients. However, if a malpractice case occurs, these charts will be used as evidence by the legal team. Since nurses often care for several patients at once, formal notes on each patient can help a nurse remember the details of the day and who was involved in the care.