Nursing notes! We're all going to have to write them. . . I had a clinical instructor who used to make us practice writing these each week. Documentation is one of the most important aspects of nursing, yes sometimes it can seem tedious, but it's best to make sure you have it down-pat! Ideally, your note should be clear, concise, to the point, and include any pertinent info/data regarding your patient (new findings - change in mental status, any change from baseline vitals, etc.). Practice makes perfect. And remember: "If you didn't document it -- it NEVER happened."
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NARRATIVE NOTE SAMPLE ENTRIES
Besides the initial entry and assessment, narrative notes include all patient care activities such as diet, hygiene, ambulation, elimination, visits from health care professionals (Dr, PT, etc) or family, tests, specific problems, how addressed and how resolved. All entry are signed and dated. Every timed entry must have a legal signature: 1st initial, last name and legal status. “M. Nurse, RN”
The last entry on a page must have a legal signature. Plan the last entry on a page so it has a logical statement and signature. You may have to have a partial blank line to do so and may have to continue the same timed entry on the next page. All blank lines have lines drawn to end of line or to signature
Each page of narrative notes is a legal document must be dated–and signed.
Safety checks: Most hospital protocols require you to document that your patient has been checked for safety at the initial entry, q 2 hours and the last entry. This must also be included in your narrative notes.
When referring to another nurse in your documentation, include her 1st initial, last name and legal title. “Pt c/o shortness of breath, P. Smith, RN notified”.
When you perform your initial assessment, you will take vital signs, briefly assess the patient’s status in all systems, and check that all ordered modalities, equipment, and treatments are in place and properly functioning. Your initial entry will include: level of consciousness; ability to follow directions; general status of the skin, respiratory system, cardiac system, and bowel sounds; the status of systems related to current diagnosis or surgery; any untoward findings; the status IVs, drainage tubes, dressings, and any special equipment; and then end with a safety check.
07:30 Alert, awake, orientated to person place and time (or A & O x3). Follows commands. Skin warm and dry. Respirations unlabored @18. AP = 82, regular. Bowel Sounds absent. Hand grasps equal. O2@ 4L via N/C. IV D5/1/2NS infusing @100 to R forearm via pump. Site clean and dry with no swelling or redness. Abdominal dressing dry and intact. Foley draining clear amber urine. Compression boots in place. TEDS in place. Bed in low position, call bell in reach, siderails up. M. Nurse, RN
The amount of fluid in CCs is recorded in the I&O sheet. In the narrative note document the type of diet, percentage consumed, and any pertinent information :
08:00 Took 100% of low sodium, soft diet. Had difficulty swallowing chopped meat._M. Nurse, RN
Documentation of complete physical assessment.
· Complete your assessment before 9 a.m. and before giving any medications or treatments. It may not all be actually completed at the same time, but document it in one paragraph making sure that any abnormal or critical findings are documented and reported immediately.
· Ask the patient specifically when he had last BM. In addition to stating of stating “no complaints of constipation diarrhea or flatus”, describe your patient’s specific status.
0830 Awake, alert, oriented to person, place & time. Skin warm and dry. Turgor recoil brisk. Face symmetrical. PERRLA. EOM intact. Follow spoken commands. Mucous membranes pink & moist. Swallows without difficulty. Neck supple, trachea midline, carotids equal, no lymph nodes palpated. JVD (-) @ 45°. Resp even and unlabored, rate 16. Breath sounds clear bilaterally & A&P. AP=72, regular. Abdomen soft, non-tender, bowel sounds present in all 4 quadrants. No complaints of constipation, diarrhea, flatus. States last BM yesterday evening. Urine amber, no complaints of burning. MAE without difficulty. Peripheral pulses 2+. Homan’s sign (-). Capillary refill brisk. Bed in low position, call light within reach. .__________________________M. Nurse, RN
Documentation of hygiene care:
Most institutions have a check-off list of nursing interventions for hygiene, such as back care, pedicure, Foley care, mouth care. However, they should be included in a narrative note. Also indicate how much of the care the patient did independently and any pertinent observations.
09:30 Complete bath care given with mouth care, peri-care, Foley care, back care.__M. Nurse, RN
Describe gait, strength, amount of assistance needed, how tolerated.
09:30 OOB to chair with the assistance of two staff members. Gait steady, but slow. Ambulated in hallway 5 minutes. C/O “feeling tired.”, assisted back to bed________________________________M. Nurse, RN
Documenting a problem such as pain:
State the problem, what was done to solve it, and record result.
10:15 States “sharp pain” points to LLQ of abdomen, 8 on a scale of 1-10. States “gets a little better when lying on left side.” Respirations 20. Demerol 75 mg IM R ventral gluteal site by M. RealNurse, RN. Side rails up, bed in low position, call light in reach. M. Nurse, RN
and the result (or evaluation of whether your intervention was successful):
11:00 States pain 3 on scale of 1-10. Watching TV.__________________M. Nurse, RN
Documenting a physician visit, a test, therapy, treatment, specimen:
10:30 Dr. Jones in to see patient._________________________________M. Nurse, RN
10:40 To x-ray via w/c for chest x-ray_____________________________M. Nurse, RN
11:45. Sputum Specimen to lab.__________________________________M. Nurse, RN
12:00 Abd dsg change. 8" midline, vertical abd incision well approximated. Staples intact. No redness, swelling or drainage noted. Dry sterile dressing applied._________M. Nurse, RN
Verify status of your patient and include safety check
12:15 States pain “almost gone”, now a 1 on 1-10 scale. Husband visiting. Watching TV. Side rail up, call bell in reach, bed in low position.___________________________________M. Nurse, RN
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