Narrative notes can be tricky for nursing students…what do you write, what if you miss something, what if you muck it all up and look like a goofball? Never fear…I’m going to give you a quick little guide on how to write an effective, legal and appropriate narrative note.
For starters, don’t write a narrative note when the flowsheet will suffice. For example, don’t write a note about your head-to-toe assessment when that information is covered in the flowsheet section of your chart. When the next nurse or the doc comes along and wants to see how the patient’s lungs have been sounding, s/he is going to look in the flowsheet for that info, and not go digging through the narratives.
So when DO you write a narrative note? You will write a narrative note for things that are outside the norm or when there is a change in patient condition. For example…let’s say your patient develops shortness of breath and decreased LOC. You will want to include the following elements in your note:
- What caused your concern? Maybe it’s the patient telling you, “I can’t breathe” or you noticed increased work of breathing when doing your assessment.
- What assessments did you conduct? Did you put the patient on the monitor, check an O2 sat, get a set of VS? Did you listen to lung sounds or observe for accessory muscle use? Did you assess skin signs, etc?
- What did you DO about it? You can’t write a note that your patient was having shortness of breath and then just go back to chatting with your coworkers. Nursing is all about DOING something. Did you put some oxygen on the patient, did you administer an anxiolytic (if it’s available and the cause of the problem), did you raise HOB…whatever you DID, you need to make note of it.
- Did you re-assess the patient? After you gave the O2, did the saturation levels go up and the work of breathing go down? If so, then yay! It worked! Whatever intervention you performed…see if it worked and include that in your note.
- And lastly, if your interventions do not work, or you still have cause for concern you are, of course, going to alert the MD. So, you’ll need to make note of who you paged or talked to…the time you did so and what the outcome was (no orders received, MD to see patient, orders received, etc…)
- If the doc gives orders, you need to write a note about how those orders helped (or didn’t help) the patient.
So let’s put it all together, shall we? Let’s say you walk into Mr. Jones room and he’s saying, ‘Nurse…I (pause for breath) can’t seem to (pause for breath) catch my breath.” So, you pop on over there and assess Mr. Jones…now note that this isn’t going to be a 10-minute assessment. You are going to quickly eyeball him and see that he is indeed short of breath and you’ve already noted that he’s speaking in 3-word phrases. Pop that pulse ox on the poor man’s finger and whip out your stethoscope. While the O2 sat is being read, take a quick listen to his lungs. You see that his O2 sat is 85% and his lungs sound wet. If your preceptor is not in the room with you, call for him/her right now. When s/he gets there you are going to calmly place a oxygen mask on your patient, all the while acting like this is the calmest situation in the world…the last thing you want to do is rile up anyone who is in respiratory distress. Calm and collected is the name of the game. You’ll sit Mr. Jones up at 45-degrees and page the doc. At no time will you leave Mr. Jones alone…that’s not cool. A few minutes later, the doc calls back, asks a few questions about fluid intake, ejection fraction, lung sounds and urine output. She orders 40mg Lasix IV and now you’re in business. But wait…before you can head out for the day, you need to write all this down in a narrative note. Ready? Let’s do this.
1420: Upon entering patient’s room, it was noted that patient experiencing SOB. Patient stated he could not catch his breath, speaking in 3-word phrases. O2 saturation 85% on RA, crackles noted on auscultation, no accessory muscle use. RN notified and summoned to room. Patient placed on 10L oxymask, HOB raised to 45%, O2 sat rose to 90%. MD paged at 1412, page returned at 1417. Orders rece—————— Joe Awesome, Nursing Student
1500: Lasix administered by RN at 1430 per MD order. O2 saturation 93% on 2L nasal cannula at this time. Crackles less pronounced, patient states he “can breathe better.” Urine output 100ml since administration of diuretic. Will wean oxygen as able and continue to monitor. —-Joe Awesome, Nursing Student
Note that this situation spans a couple of narrative notes. That’s how it goes sometimes if your intervention is going to take a little bit of time to work. Something else you would also want to do is get a full set of VS, and chart those in the flowsheet. You’ll also probably increase your assessment interval for Mr. Jones for a while until you are convinced he has stabilized. Pretty sure he’ll be glad you did! And don’t worry…all of your charting will be checked over and “double-signed” by the RN you are working with, which makes it totally legit!
Hope that helps you write amazing, articulate, organized and efficient narrative notes. Don’t be afraid to get into that chart and document all the awesome and wonderful work that you do!
Be safe out there!