Write nursing notes

Add a dated nursing note for an admitted patient, with the advice followed and a progress remark.

A nursing note records what the nurse observed or did for the patient at a given time. Each note carries the date and time, the nurse's name and a free-text progress note. The notes build up as a list for the whole stay.

note

Who can do this: nurses with Ward Management rights

Where: Nursing Work Bench › Ward Management › three dots on the bed › Intake / Output › Nursing Notes tab. Also Nursing Work Bench › SC Nursing › patient › Nursing Notes.

Before you start

• The patient is admitted to a bed. See Admit a patient.

Add a note

1. Go to Nursing Work Bench › Ward Management and find the patient's bed. See See the patients in your ward.
2. Click the three dots on the bed card and choose Intake / Output. The Nursing Chart opens with the patient's name, UHID, IP number and bed at the top.
3. Click the Nursing Notes tab.
4. Check Date & Time. It is set to now.
5. Type what was done in Treatment / Advice, and the observation in Remarks / Progress Note. Fill the other fields when they apply.
6. Click Save. The note appears in the list below with your name.

Fields on the form

Field	What to enter	Required
Date & Time	When the note applies. Now by default.	Yes
Weight (kg)	The patient's weight, when measured.	No
Case Type	IPD for an admitted patient.	No
RBS, Latest Creatinine, Creatinine Clearance	The latest values, when known.	No
Treatment / Advice	The treatment or advice followed. Type it, or click Select Advice to pick from the hospital's advice list.	No
Procedure	A procedure done for the patient. Type two letters and pick it.	No
Route	The route used, for example Oral or IV.	No
Remarks / Progress Note	The observation, up to 4000 characters.	No

Change or delete a note

1. Find your note in the list.
2. Click the pencil icon to change it, then click Update. Click the bin icon to delete it.

Good to know

• You can change or delete only the notes you wrote.
• Select Advice opens the hospital's advice list. Tick the lines you need and click Add selected. You can add a new line to the list there.
• In SC Nursing, open the patient and tap Nursing Notes to write the same note at the bedside.

Troubleshooting

What you see	What it means	What to do
Patient is discharged. Nursing notes are read-only.	The stay is closed.	No new note can be added for this stay.
The pencil and bin icons are missing on a note	Another nurse wrote the note.	Add a new note with the correction.
Save is greyed out	The note is empty, or Date & Time is blank.	Set the date and time and type the note.

Related

• Record vitals for an admitted patient: the readings that go with the note.
• Record intake and output: the first tab of the same chart.
• Nursing Work Bench FAQs: common questions on nursing charting.