When I write nurses notes I try not to state more than is needed. I add any scale of c/o pain such as…c/o pain on scale 8/10. If the resident says something I put… res. stated “I don’t feel well, my head is hurting”, then say what I did about it such as pain relief given. If there is a change in anything like B/P or LOC I always add that. I also always put…call light in reach and water at bedside.