Nurse Charting 101 | Berxi™ (2023)

Nurse Charting 101 | Berxi™ (1)

You covered a lot of ground in nursing school. While you may feel more than ready to place an IV or take vitals, you might be a little less confident when it comes to charting. It might seem strange that the paperwork is what makes your palms sweat, but it makes sense. Patient documentation is permanent record, and, well, you probably became a nurse for the hands-on interaction.

That’s OK! Here’s a refresher on what and how to chart as a nurse, as well as tips for avoiding some of the most common documentation mistakes.

The Importance of Documentation in Nursing

Charting isn’t an afterthought or mindless paper-pushing; it’s a crucial part of your role as a nurse, says Michael Zychowicz, DNSc, MSN, BSN, a clinical professor of nursing at Duke University’s School of Nursing. Effective documentation can:

  • Help a large, interprofessional healthcare team communicate with each other.
  • Ensure that the quality of patient care doesn’t suffer from one shift to the next, or while being transferred across care teams.
  • Create a record of billable services for insurance companies or other payers.
  • Protect you in the event of a lawsuit.
  • Demonstrate your contributions as a nurse.

What Types of Things Should You Document in a Patient’s Chart?

The information you put in a patient’s medical record should more or less track the nursing process. Your charting generally should include:

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  • Authorship Details: For example, the date/time the note was written, as well as your full name, credentials, and signature.
  • Your Assessment of the Patient: This includes your interpretation of the findings and any diagnosis.
  • Objective Data: What your assessment told you.
  • Subjective Data: What the patient told you.
  • Plan of Care: This includes modifications to an existing care plan, evaluation notes on how well the care plan is going, or self-care instructions for the patient.
  • Interventions You Implemented: For example, any procedures or medications administered.
  • Consultations or Referrals: This includes details about the provider’s name and affiliation.

If you aren’t sure you’ve included everything you need to, ask yourself: “If another nurse needed to step in and care for this patient, would the chart give them everything they needed to do it seamlessly?”

What Are the Different Types of Nurse Charting?

Nurses have different ways of charting similar information, and there’s no one best way, says Krysia Hudson, DNP, RN, BC, an assistant professor at the Johns Hopkins School of Nursing. As long as you get down all the important information, Hudson says, it doesn’t really matter how you go about it. That said, there are a few different approaches you could take, and each has their own advantages and drawbacks.

1) Narrative Notes

Narrative nurses notes are like a running log of everything that happened with the patient during a particular shift. The benefits of narrative notes are that they’re straightforward, easy to do, and simple to follow. At the start of a shift, nurses can read through the log and get a good sense of what happened before they arrived.

But narrative notes can also be pretty repetitive and disorganized. Nurses during different shifts might be focusing on different problems, and you have to read through the entire chart to get a real feel for how the patient is doing overall. Another drawback, according to Hudson, is that even seemingly objective notes could, in reality, be subjective. You could use three words to say a foot looks pink, but other healthcare providers might interpret that hue differently.

Example of Narrative Notes

Date Time Progress Notes
11/15/2013 0815 Assessment performed, resident with C/O SOB, states, “I just can’t seem to catch my breath, and I am coughing up green phlegm.” On auscultation, breath sounds decreased in bases bilaterally, coarse rhonchi bilaterally in upper lobes, accessory muscle use noted bilaterally, breathing is shallow and lips are cyanotic. Vital signs assessed; temp: 100.5, BP: 110/76, HR: 108, RR: 32, SpO2: 95% on room air. ‐‐‐‐‐‐ J.Smith, RN
0820 Assessment findings reported to Dr. Halifax ‐‐‐‐ J. Smith, RN
0825 Resident assessed by Dr. Halifax ‐‐‐‐‐‐ J. Smith, RN

Example from the Texas Department of State Health Services

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2) Charting by Exception

Instead of comprehensive note-taking, charting by exception (CBE) documents only things that are outside the norm. The beauty of CBE is that it takes significantly less time to do, giving nurses more time to focus on other tasks.

But while Hudson says she prefers CBE, it does have its downsides. In order to chart by exception, you have to first know what’s considered “normal” for any given patient. Every organization has its own defined limits, and those standards might not actually reflect what’s “normal” for some patients. For example, someone who has had a liver transplant might never have bilirubin levels within a normal range. CBE can also leave out really valuable information that makes it hard to know whether a patient’s condition is changing or if certain procedures were truly conducted.

CBE can look very different from one healthcare environment to the next,
depending on the documentation tools they use. Many clinical settings that use CBE generally rely on checklists and flow sheets to document patient information, allowing nurses simply to check some boxes or quickly sign their initials before moving onto the next patient.

CBE: Checklists and Flow Sheets

These pre-made templates (usually one to two pages when they’re printed out) list all the data, services, and measures relevant to a particular type of visit, assessment, or condition. They consist mainly of boxes to check and short, blank spaces to fill out, making them typically quicker and easier to fill out than, say, writing a long narrative.

The standard template also makes it easy to compare metrics across visits or spot anything out of the norm for the patient. For example, if you have a standard admission template that always has vital signs along the top of the page, you can easily see if the patient has gained weight or lowered their blood pressure compared to previous visits.

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But the information conveyed by flow sheets or checklists is far from exhaustive. With little room for narrative, these templates only provide a narrow snapshot of what’s happening with a patient. As a result, they’re often used to complement (rather than replace) other forms of nursing notes or charting.

3) SOAP(IER) Notes

SOAP(IER) stands for “subjective,” “objective,” “assessment,” and “plan,” with some nurses choosing also to add “intervention,” “evaluation,” and “revision.” Nurses generally use this acronym to guide them when they’re charting about a particular problem or medical condition. It’s broken down like this:

  • Subjective: This section covers history (e.g., medical history or symptom progression), as well as any relevant information, questions, or concerns told to you by the patient or their friends or relatives.
  • Objective: This is where you add the hard data (e.g., vital signs, labs, exams, etc.) observed during the visit.
  • Assessment: Once you note the observations, then you can move on to your assessment. What is the primary medical concern? What else might be going on? Whatever you put here should be supported by the information given in the first two sections.
  • Plan: Now that you have your diagnosis, what should happen next? Use this space to discuss the outline or updates to the patient’s care plan, including any prescriptions, self-care instructions, follow-ups, or referrals.
  • Interventions: Here’s where you put anything you did for the patient to address the problem identified. Did you give them medications? Put up the bed rail? Place the call button within reach? Don’t forget any instructions or education you verbally conveyed to the patient.
  • Evaluation: This section is where you note how well the intervention(s) worked, usually in the form of objective or subjective data.
  • Revision: If your evaluation signals that you should tweak your intervention, you’d then note here what changes (if any) are being made to the care plan.

While SOAP(IER) notes have been widely used in healthcare settings, they’re becoming less and less common, Hudson says. This is due, at least in part, to how time-consuming they are. Using this process for each individual problem can mean inputting a lot of the same information, especially if problems overlap.

Example of SOAP(IER) Charting

Date Time Progress Notes
05/01/2012 1730
    S - Pt: “I don’t feel well.”
    O - Temperature 102.4°F
    A - Fever
    P - Offered extra fluids, monitor body temperature
    I - 750mL of fluid intake in 8 hours; assess temperature every 4 hours
    ‐‐‐‐‐‐ J.Doe, RN
    E-Temperature reduced to 101°F
    R-Increase fluid intake to 1000mL per shift until temperature is less than 100°F
    ‐‐‐‐‐‐ J.Doe, RN

Example adapted from Fundamental Nursing Skills and Concepts, page 114

4) PIE Charting

Similar to SOAP(IER), PIE is a simple acronym you can use to document specific problems (P), as well as their related interventions (I) and evaluations (E). Nurses write down their assessment on a separate form or flow sheet in the patient’s chart and assign each individual problem a number. Every time they refer to that particular issue in the patient’s chart, they use that assigned number.

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The whole process is problem-oriented like SOAP(IER) and covers much of the same ground, but it’s a little simpler to use.

Simpler, however, isn’t always better. Unlike more comprehensive documentation processes, PIE charting doesn’t specify a fundamental care plan. That means different nurses might try to solve the problem in different ways, potentially resulting in inconsistent care.

Example of PIE Charting

Date Time Progress Notes
02/01/2008 1320
    P#1 - Risk of aspiration secondary decreased level of consciousness.
    I#1 - Head of bed elevated 45 degrees while eating and for one hour after eating. Liquids thickened and fluids given with straw. Dr. B. Jones notified. Ativan DC’d.
    ‐‐‐‐‐‐ B. Moore, RN
    E#1 - No aspiration. Client alert and responsive. ‐‐‐‐‐‐ B. Moore, RN

Example from

5) Focus (DAR) Charting

Focus charting uses the DAR process (i.e., “data,” “action,” “response”) to guide and organize nursing notes. Similar to problem-centered charting, DAR charting organizes notes by focus (thus the name) that can span health changes, patient concerns, or specific events, in addition to traditional medical problems. The focus is identified during the assessment, and then nurses note the specific actions they took, as well as how the patient responded to those actions.

The big advantage to focus charting is that it’s easy to do because the steps follow the nursing process pretty closely. But it can also be a little confusing, especially for new nurses. The DAR statement is typically recorded in addition to other forms of documentation like flow sheets, which can make notes feel a little disorganized.

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Example of Focus (DAR) Charting

Date Time Focus Progress Notes
02/01/2008 1320 Fever
    D: Temperature 102°F orally. Face flushed. Frontal headache (2 on a 0-10 pain scale).
    A: Acetaminophen 500mg orally. Cool compress to forehead. 400ml apple juice. Recheck temperature in 1 hour. --------- M. Brown, RN
1420 Fever
    R: Temperature 99.8°F orally. Face remains slightly flushed. No headache. --------- M. Brown, RN

Example from

Nursing Documentation Dos & Don'ts

As important as documentation is, mistakes can happen. Here’s how you can avoid some of the most common charting errors in nursing.

Nursing Documentation "Dos"

  1. DO document in a timely manner. Wait too long and your note might not be as accurate as it could be, or worse, other providers seeing the patient could be left without the information they need to do their jobs. If you have a delay in adding your notes, be sure to note that it’s a late entry so there’s no confusion over what happened and when.
  2. DO double-check templates to make sure they’re accurate. Electronic health record (EHR) templates and macros can be huge time-savers by automatically filling in notes for routine exams, but they can also introduce errors into the chart if you’re not careful. Make sure every checked box and note is accurate for the individual patient.
  3. DO verify that you have the correct chart. The name might be right, but is the birthdate? Even with EHRs, chart mix-ups can happen, and that can lead to medical errors. Before jotting down your notes, be sure that the file you’re looking at truly belongs to your patient by following the Joint Commission’s standard of using at least two personal identifiers.
  4. DO spellcheck. A typo or three might seem like no big deal in the grand scheme of things, but even small mistakes can come back to bite you, Zychowicz says. In the event of a lawsuit, for example, a lawyer might try to argue that if you’re careless with your charting, you might’ve been careless in your other nursing duties, too. Be as professional with your documentation as you are with your patients.
  5. DO ask other nurses for tips and tricks. Nurses are being asked to take on more and more paperwork without more time to do it, and that can be overwhelming. Avoid burnout by asking your fellow nurses for their favorite shortcuts or techniques to make charting more efficient.

Nursing Documentation "Don’ts"

  1. DON’T make assumptions. If you didn’t see a patient fall on the floor, don’t put it in the patient’s record, Hudson says. You didn’t walk in and see that “the patient had fallen on the floor.” You walked in and “saw the patient lying on the floor.” Stick to the facts.
  2. DON’T use unclear abbreviations. Abbreviations can save time, but they can also cause confusion. Check your clinic’s policies and procedures for guidance on what abbreviations you can use. If you aren’t sure, spell it out.
  3. DON’T rely too much on transcriptions. Not all voice-to-text software programs or transcription services are 100 percent accurate. Sometimes words can be switched out or removed, effectively changing the meaning of the note. Before posting the text to the patient’s chart, read through it to make sure it says what you want it to say.
  4. DON’T leave out important information. When you’re rushed for time, it can be easy to leave out things that seem routine. But as the adage goes, “If you didn’t write it down, it didn’t happen.” Any contact with the patient (e.g., interventions, exams, instructions, referrals, etc.) should go into the chart. Leaving out relevant information could result in medical errors or lawsuits down the line.
  5. DON’T over-chart. You want to be thorough, and that’s great! But don’t feel like you have to write a novel in every chart or even use complete sentences, Zychowicz says. It’s just too time-consuming, and chances are you don’t really have the time. Chart what you need to, and then move along.

Image courtesy of


What are the basic rules of nursing documentation? ›

Nursing Documentation Tips
  • Be Accurate. Write down information accurately in real-time. ...
  • Avoid Late Entries. ...
  • Prioritize Legibility. ...
  • Use the Right Tools. ...
  • Follow Policy on Abbreviations. ...
  • Document Physician Consultations. ...
  • Chart the Symptom and the Treatment. ...
  • Avoid Opinions and Hearsay.

How do I document my nursing notes? ›

How to Write Nursing Progress Notes: A Cheat Sheet
  1. Date and time.
  2. Patient's name.
  3. Nurse's name.
  4. Clinical assessment, e.g. vital signs, pain levels, test results.
  5. Details of any incidents.
  6. Changes in behaviour, well-being or emotional state.
  7. Changes in the care provided.
  8. Instructions for further care.
Jun 30, 2022

What is the best type of charting for nurses? ›

Common formats used to document patient care include charting by exception, focused DAR notes, narrative notes, SOAPIE progress notes, patient discharge summaries, and Minimum Data Set (MDS) chartin g.

What are the basic rules of charting? ›

All recording on the chart should be neat, legible, intelligent and meaningful. Statements must be accurate, relevant and concise. (a) Terse statements instead of complete sentence are used. (b) Correct spelling and only acceptable and official abbreviations are to be used.

What are the 3 C's of documentation? ›

The 3 C's of accurate documentation:
  • Be Clear. The first step in any problem solving is identifying the problem and writing it down as a problem statement. ...
  • Be Concise. Note-taking while listening and speaking to someone on the phone may mean writing in phrases. ...
  • Be Complete.
Sep 3, 2013

What should you not chart in nursing notes? ›

  • Don't chart a symptom such as “c/o pain,” without also charting how it was treated.
  • Never alter a patient's record - that is a criminal offense.
  • Don't use shorthand or abbreviations that aren't widely accepted.
  • Don't write imprecise descriptions, such as "bed soaked" or "a large amount"

What are the C's of medical charting? ›

The Six C's of Medical Records

Medical assistants should memorize these terms, six C's to maintain accurate patient medical records. Client's Words, Clarity, Completeness, Conciseness, Chronological Order and Confidentiality.

What is an example of charting in nursing? ›

Some examples of charting include documenting medications administered, vital signs, physical assessments, and interventions provided. Nursing notes are a narrative written summary of a given nursing care encounter. This might include a description of a nursing visit, a specific care event, or a summary of care.

What is a good nurses note? ›

Nursing notes include information about how the patient feels, what they need, and what's going on with their health in a short, detailed summary. When you put every piece of information together, make sure that everyone who needs to know about a patient's care can access that information quickly and easily.

What is the golden rule of charting? ›

1. Thou Shalt Document Timely, Adequately, and Accurately. 2. Thou Shalt Write Legibly.

What do nurses do when charting? ›

Charting in nursing provides a documented medical record of services provided during a patient's care, including procedures performed, medications administered, diagnostic test results and interactions between the patient and healthcare professionals.

Is charting hard in nursing? ›

It can be difficult to chart an entire patient encounter and not miss details, and going through your personal system that you've created can help you minimize charting errors.

What is the most common type of charting? ›

Bar Chart. Bar charts are one of the most common data visualizations. You can use them to quickly compare data across categories, highlight differences, show trends and outliers, and reveal historical highs and lows at a glance.

What is the hardest topic in nursing? ›

Hardest Nursing School Classes
  • Pathophysiology. In this course, students learn how different anatomical systems work and how diseases or injuries affect these systems. ...
  • Pharmacology. ...
  • Medical Surgical 1 (also known as Adult Health 1) ...
  • Evidence-Based Practice.

What is the hardest thing in nursing? ›

Here are some of the challenges nurses face in their profession:
  1. Long shifts. Nurses often work 10- or 12-hour shifts. ...
  2. Changing schedules. ...
  3. Emotional involvement. ...
  4. Physical demands. ...
  5. Exposure to illness and chemicals. ...
  6. Lack of nurses. ...
  7. Changing technology. ...
  8. Poor treatment from patients.
Mar 10, 2023

What are the hardest nursing tasks? ›

The most stressful nursing jobs include ICU nurse, ER nurse, and NICU nurse. In these roles, nurses work in an intense environment with high stakes. They manage emergency situations and care for critically ill patients. Other stressful nursing jobs include OR nursing, oncology nursing, and psychiatric nursing.

What are the 5 principles of good documentation? ›

Be clear, legible, concise, contemporaneous, progressive and accurate.

What is an example of bad nursing documentation? ›

Examples of poor documentation include not charting follow up of nursing interventions, not reviewing dictated documentation before signing it, including the wrong date and/or time, not documenting significant changes in the patient's condition, adding multiple addenda (which can be perceived as an attempt to cover ...

What are the 4 methods of documentation? ›

The four kinds of documentation are:
  • learning-oriented tutorials.
  • goal-oriented how-to guides.
  • understanding-oriented discussions.
  • information-oriented reference material.

What mistake should a nurse never make? ›

Dispensing the wrong medication, dispensing the wrong dose of medication, giving a medication to the wrong patient, and failing to monitor patient's condition are some of the errors under this category. Keep in mind a are potentially life-threatening to patients.

What are 3 things you should not add to a medical record? ›

The following is a list of items you should not include in the medical entry:
  • Financial or health insurance information,
  • Subjective opinions,
  • Speculations,
  • Blame of others or self-doubt,
  • Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,
Mar 23, 2010

What should not be included in a patient chart? ›

7 Common Pitfalls to Avoid in Charting Patient Information
  • Failing to record pertinent health or drug information. ...
  • Failing to document prior treatment events. ...
  • Failing to record that medications have been administered. ...
  • Recording on the wrong patient's chart. ...
  • Failing to document discontinuation of a medication.

What are the 4 C's of nursing? ›

The four primary care (PC) core functions (the '4Cs', ie, first contact, comprehensiveness, coordination and continuity) are essential for good quality primary healthcare and their achievement leads to lower costs, less inequality and better population health.

What are the 5 C's of documentation? ›

To introduce you to this world of academic writing, in this chapter I suggest that you should focus on five hierarchical characteristics of good writing, or the “5 Cs” of good academic writing, which include Clarity, Cogency, Conventionality, Completeness, and Concision.

What are the 7 C's in healthcare? ›

The 6Cs of nursing are a mix of qualities that all nurses live by when working with service users – Care, Compassion, Competence, Communication, Courage, and Commitment.

What are the six principles of documentation? ›

If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation.

How do you end a nursing note? ›

All nurses' notes should be ended with the nurse's signature and title. For example: Darby Parker, RN, BSN. Some facilities require nurses to include the date and time at either the beginning, ending, or both of each entry.

What are good documentation practices? ›

Good Documentation Practices, commonly referred to as GDPs, are the guidelines that one follows in recording raw data entries in a legible, traceable and reproducible manner. A key to Good Documentation Practices is to consider these questions each time you record your raw data: 1. Is it true?

What does pie stand for in nursing? ›

Pulmonary interstitial emphysema (PIE) is when air gets trapped in the tissue outside of tiny air sacs (alveoli) in the lungs. It affects newborn babies. PIE is fairly common in neonatal intensive care units (NICUs).

How do you chart vitals? ›

Temperature, pulse, respira- tion, and blood pressure are usually taken in this order. For proper charting of vital signs in the medical record, it is helpful to remember the T, P, R, BP sequence and record the results in that order.

What are some nurses sayings and phrases? ›

Top 10 Classic Nurse Sayings
  • "They may forget your name but they will never forget how you made them feel.” – Maya Angelou.
  • "You treat a disease: You win, you lose. ...
  • "To do what nobody else will do, in a way that nobody else can do, in spite of all we go through ... that is what it is to be a nurse.” – Rawsi Williams.

What nurses usually say? ›

Top 12 phrases that nurses say most
  • “Have you had a bowel movement today?”
  • “When was the last time you had anything to eat or drink?”
  • “Are you allergic to any medicines?”
  • “You have gorgeous veins.”
  • “You're not going to die.”
  • “You'll feel a little pinch.”
  • “Take a deeeeep breath.”
  • “Drink this.”

What do you write in patient notes? ›

These characteristics include:
  1. A title (of the event, diagnosis, or treatment).
  2. The information about (History when/where/how) the medical event took place.
  3. The date when the document was written and when the event took place (no more than a 24 hr. ...
  4. The patient's full name and date of birth.
  5. The patient's illness area.

What are the 3 C's in charting? ›

The 3 C's of Process Documentation (Consistency, Compliance, Completeness) And Why You Should Care.

What is the number 1 golden rule? ›

1. Common Observations and Tradition. “Do unto others as you would have them do unto you.” This seems the most familiar version of the golden rule, highlighting its helpful and proactive gold standard.

Why do nurses have to chart so much? ›

Charting provides invaluable details that inform patient care decisions. Without accurate information provided by charting, physicians and nurses are working inefficiently.

What is a nursing soap note? ›

SOAP—or subjective, objective, assessment and plan—notes allow clinicians to document continuing patient encounters in a structured way.

Why do nurses chart in third person? ›

Charting in third-person is considered more formal and professional, and in the case of documenting patient care – this point-of-view reads more objectively (as this type of documentation should be) and puts the patient as the focus of the documentation.

How long does it take nurses to chart? ›

Here's what they found: 30% of facilities require that charts be completed within 24 hours of a patient encounter. 29% of facilities require that charts be completed within 48 hours of a patient encounter. 20% of facilities require that charts be completed within 72 hours of a patient encounter.

How long does it take to chart a patient? ›

Physicians should aim to complete charts immediately after treatment when details are still fresh. Most hospitals set time limits for when documentation is due: within 24 hours for admitting notes, 48 hours for surgical procedures and 15 days after discharge for completing the record.

What is the easiest level of nursing? ›

As registered nursing degree programs go, the easiest one out there is the ADN. An associate's degree program can prepare you for a career as a registered nurse, but you should know that this degree meets only the bare minimum requirement for qualification as an RN.

What is charting procedures? ›

In simple terms, charting is documentation to have a record of patient status, medical services and more. It may include test results, medication history, health history and any procedures the patient has undergone throughout their lifetime.

What is nursing note format? ›

A nursing narrative note is a type of nursing documentation used to provide clear, detailed information about the patient. A narrative note is written in paragraph form and tells a story, if you will, about the patient, the care he is receiving, response to treatment, and any interventions or education provided.

What are the soap notes for nurses? ›

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan. Each heading is described below. This is the first heading of the SOAP note. Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them.

What are the 5 C's in patient charting? ›

Client's Words, Clarity, Completeness, Conciseness, Chronological Order and Confidentiality.

How do you write patient notes fast? ›

How To Write Medical Progress Notes Faster
  1. Use templates.
  2. Use checkboxes and dropdown lists.
  3. Save standard terms, phrases, and descriptors.
Oct 14, 2022

What is the hardest type of nurse to be? ›

Most Stressful Nursing Positions
  • Intensive Care Unit (ICU) nurses. ICU is an extremely high-pressure environment and these nurses work with patients who have significant injuries and disease with added morbidity risks. ...
  • Emergency Department nurses. ...
  • Neonatal ICU. ...
  • OR nursing. ...
  • Oncology Nursing. ...
  • Psychiatric Nursing.
Jan 27, 2021

What is the hardest thing as a nurse? ›

Here are some of the challenges nurses face in their profession:
  1. Long shifts. Nurses often work 10- or 12-hour shifts. ...
  2. Changing schedules. ...
  3. Emotional involvement. ...
  4. Physical demands. ...
  5. Exposure to illness and chemicals. ...
  6. Lack of nurses. ...
  7. Changing technology. ...
  8. Poor treatment from patients.
Mar 10, 2023

What is the hardest thing a nurse has to do? ›

Seeing the death of their patients.

"Seeing those patients you took care of die and how devastating it is to the family" is the hardest part of being a nurse, said Melissa, a nurse from Oklahoma city.


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