{"id":338,"date":"2026-10-20T18:00:00","date_gmt":"2026-10-20T18:00:00","guid":{"rendered":"https:\/\/siplingo.com\/blog\/?p=338"},"modified":"2026-10-31T09:09:53","modified_gmt":"2026-10-31T09:09:53","slug":"pflegebericht-schreiben","status":"publish","type":"post","link":"https:\/\/siplingo.com\/blog\/pflegebericht-schreiben\/","title":{"rendered":"Pflegebericht schreiben: How to Write a Nursing Report in German"},"content":{"rendered":"

To write a good Pflegebericht, describe what you saw, heard and measured, not what you think: with date, time and your initials, specific values, the person’s own words in quotation marks, and no judgments or unapproved abbreviations. Pflegebericht schreiben is mostly about changes, deviations from the plan and the effect of what you did.<\/p>\n\n\n

Checked in October 2026 against \u00a7 630f of the German Civil Code (BGB, patient records), the einSTEP project pages on the Strukturmodell, explanatory notes on efficient care documentation by the Medizinischer Dienst (MD Bayern) and nursing documentation guidance from the canton of Aargau (Switzerland). Details depend on your facility and its software, so follow your Dokumentationsstandard.<\/em><\/p>\n\n\n

What a Pflegebericht is for<\/h2>\n\n\n

The Pflegebericht (also Pflegeverlaufsbericht<\/em> or Berichteblatt<\/em>) is the running record of what happened with a patient or resident. It has three jobs:<\/p>\n\n\n

  1. Continuity.<\/strong> The next shift, the doctor and the therapists learn what changed without having to ask you.<\/li>\n\n
  2. Legal proof.<\/strong> In a hospital, nursing notes are part of the patient record. \u00a7 630f BGB says records must be kept in close time connection with the treatment, corrections are allowed only if the original content and the time of the change stay visible, and records are kept for ten years after treatment ends unless other rules apply. Care homes and home care services work under further rules of their own, but the same principles are taught there. A sentence many nursing schools repeat: what is not documented is hard to prove was done.<\/li>\n\n
  3. Quality checks.<\/strong> Documentation is what an inspector or the Medizinischer Dienst can read later.<\/li>\n<\/ol>\n\n\n

    In care homes that use the Strukturmodell, the report has a narrow focus. The MD Bayern notes say deviations from the planned measures and current observations go into the report, while routine care that runs as planned is described once in the Ma\u00dfnahmenplan. The Aargau guidance makes a similar point: the progress report is not a list of tasks done. Hospitals often record routine values in a chart (Kurve<\/em>) instead. Your facility decides the exact split.<\/p>\n\n\n

    Wie formuliere ich einen Pflegebericht richtig? 9 rules<\/h2>\n\n\n
    1. Objective.<\/strong> Write what you saw, heard, smelled or measured. Bewohnerin weinte beim Fr\u00fchst\u00fcck.<\/em> Not: Bewohnerin war traurig.<\/em><\/li>\n\n
    2. Specific.<\/strong> Times, amounts, places, values with units: Trinkmenge 7\u201314 Uhr: 600 ml.<\/em><\/li>\n\n
    3. Date, time and signature.<\/strong> Each entry gets date, time and your initials (Handzeichen<\/em>), or your login in the software.<\/li>\n\n
    4. Promptly.<\/strong> Write close to the event, not at the end of the week.<\/li>\n\n
    5. No judgments or labels.<\/strong> Describe behaviour, not character.<\/li>\n\n
    6. Own words in quotation marks.<\/strong> Bewohner sagt: \u201eIch will nach Hause.\u201c<\/em><\/li>\n\n
    7. Only approved abbreviations.<\/strong> Use your facility’s list (Abk\u00fcrzungsverzeichnis<\/em>); see German nursing abbreviations<\/a>.<\/li>\n\n
    8. Measure, effect, next step.<\/strong> What you did, how the person reacted, who you informed, what happens next.<\/li>\n\n
    9. Correct visibly.<\/strong> On paper, never use correction fluid, never overwrite or black out. Strike through once so it stays readable, then add date and initials. In software, use the correction function; the system should keep the original version.<\/li>\n<\/ol>\n\n\n

      Whether you must write something every shift or only when something changes depends on your facility’s standard. Ask on your first day.<\/p>\n\n\n

      Tense and style<\/h2>\n\n\n