Written by Brandon L.
August 08, 2024 9 min read Share this article
Can't seem to figure out how to write a nursing narrative note? Well, you are in the right place. Whether you are a student whose main goal is to finish an assignment or a practicing nurse, knowing how to write narrative documentation is essential. A nursing narrative note records information such as evaluation, assessment, diagnosis, action plans, and evaluations of interventions given to a patient. The standards for writing these notes are high because they help reduce medical errors and ensure continuity of care.
In this guide, writers from our nursing essay writing service will help you understand how to write effective nursing narrative notes. They will provide step-by-step instructions, an example, a template, and practical tips to enhance the quality of your document.
Nursing narrative notes are a type of documentation that provides comprehensive details about a patient and all the care given to them. The note is written in chronological order, accounting for what brought the patient to the hospital, objective clinical observations, assessments, and the care plan.
When writing a nursing narrative note, ensure that you clearly and concisely document interventions, medications administered, patient responses, and any communications with other healthcare providers. Including all this information and following the proper format facilitates communication between different healthcare providers and ensures continuity of care.
Nursing narrative notes are a type of charting used to communicate important information about a patient, such as interactions, observations, care provided, etc. The narrative notes offer a chronological account of the patient's illness/ condition, treatment, response to treatment, and any other changes they experience.
A well-written narrative note provides a comprehensive and personalized description of the patient by providing objective and subjective data.
On the other hand, charting is a more structured and standardized means of documenting in nursing. It includes a checklist, flow sheets, and an electronic health record (EHR) template to ensure all patient information and procedural details are captured.
Charting and nursing narrative notes are both essential communication methods that accurately represent what is happening to the patient and what the nurse is doing to help them.
Writing nursing narrative notes is essential for the following reasons:
Continuity of care is an approach that ensures a patient receives quality care from their healthcare team. A nursing narrative note helps facilitate communication between different healthcare team members by ensuring nurses taking over a shift can get on the same page by quickly reading over the patient's illness, condition, and treatment.
A detailed nursing narrative note acts as a legal record of the care given to patients. This means if there is ever an issue about nurses' misconduct in malpractice litigation, this document can act as proof that the patient received the care.
Follow these steps to write your nursing notes.
Begin by collecting all the necessary information to include in your nursing narrative note. Remember, a nursing narrative note must include essential patient information such as the name, date, time, interventions, recent medical histories, and nursing care plans.
So, conduct an assessment before you begin writing. Nursing assessment refers to the process in which a nurse gathers, sorts, and analyzes crucial information about the patient to learn more about their overall health. It involves considering social, biological, cultural, psychological, and spiritual beliefs and values.
Use the following techniques to make head-to-toe assessments: inspection, palpation, percussion, and auscultation.
Conduct physical exams, which involve taking patients' vital signs, heart rate, blood pressure, respiratory rate, etc. A physical exam also involves taking into account the emotional state, posture, and hygiene of the patient. To gather this information, begin asking the patient questions and examining the patient from head to toe. When checking the head, including the ears, eyes, nose, mouth, and throat.
In some cases, particularly young children or incapacitated patients, you can get the information from the parents, guardians, friends, etc.
Missing any of these details will make your chart incomplete and unable to communicate the necessary information accurately.
In addition, ensure you understand the current health status of the patient and whether they have received any treatments.
Writing a nursing narrative note is about following the right format to ensure your notes are well organized. There are two standard formatting you can use: SOAP and DAR.
SOAP:
DAR:
Please note that each entry should be focused on one problem to ensure that one can read and understand what is being communicated.
Additionally, you can use SBAR, a method of communication that stands for introduction, situation, background, assessment, and recommendation. ISBAR in nursing is used to organize information ensuring simplified and effective communication.
Once you have gathered all the patient's information, you can begin writing the note. The first information to provide is the basic information about the patients.
Write down their full names, gender, date of birth, and medical record number. This information will help identify who the patient is and what brought them to the hospital.
Also include the attending nurse's name.
You must clearly identify who the patient is to avoid reporting on the wrong patient.
In addition to patient information, provide the date and time you wrote the narrative note. If the different diagnoses were made at different times, ensure you note the time for each.
Including the date and time will help establish a timeline and help physicians identify important information that is related to a specific event.
Subjective data refers to information that comes from patient's opinions or experiences. It includes information such as pain level, symptoms, concerns, etc.
Write down all the information the patient provided about the subject. Ensure you detail this as much as possible. For instance, you can identify the site of the pain, the degree of pain, the frequency of pain, and the description of the character of the pain.
Next, provide information factual information that you, as a professional, observed from the patient based on the tests conducted, regardless of what the patient says. Objective data could include information such as:
Ensure you also provide a clear picture of the patient's current condition and any changes or abnormalities observed.
Based on the subjective and objective data, provide a clinical interpretation. This stage is based on your clinical judgment from your skills, knowledge, and experience. For instance, you could say something like, based on lab results and patient symptoms, the patient has Urinary Tract infection.
Describe all the actions you performed to help the patient deal with their illness. If you gave them medications, state the method used, frequency, and duration of administration.
Whatever interventions you provide, ensure you connect them with your assessment of the patient. For instance, you can say I administered 5 mg of IV morphine sulfate through an IV line in the right forearm as per Dr. Johnston’s orders to help relieve the patient's pain.
Write down how the patient repossessed the treatments and interventions given. Additionally, write down whether there were changes in the patient's condition or the symptoms they experienced.
Document the follow-up actions or the next steps for the patient's treatment or care to help them get better. These actions include future assessments, additional treatments, or referrals to specialists or other healthcare providers.
Furthermore, if any care plan adjustments were made based on the patient's status, write them down. Ensure the attending physician signs up for this.
Patient Information
Date and Time: 05/19/2024, 10:00 AM
At 9: OO AM, the patient reported pain in the lower abdomen and rated it at 9/10. She experienced sharp stabbing pain on the right side of her abdomen, which had been increasing in intensity with each passing hour.
Assessment:
Lindsay's recent vital signs were a BP 130/80, HR 72, RR 16, and Temp 98.6°F. She was alert and oriented. Her skin was warm and dry, with no signs of edema. The patient's breathing sounds clear bilaterally. Her abdomen was soft non-tender. The patient also reported mild chest discomfort, 3/10 on the pain scale, radiating to the left side.
As per the doctor's orders, I administered 325 mg of aspirin PO. I also educated the patient on the importance of taking their medication and monitoring the side effects they may experience afterward.
Response
After the intervention, the patient reported a reduction in chest discomfort to 1/10 within 30 minutes of aspirin administration. No adverse reactions were observed.
The plan is to perform an EKG as ordered by Doctor Johnston and monitor the results. I will also assess the patient’s pain and symptoms every hour and continue to monitor their vital signs every 4 hours.
If you want to avoid the stress of writing a nursing note and complete your notes quickly, consider using a nursing narrative note template. A nursing narrative note template is a structured roadmap that you can use to document a patient's care effectively and consistently. Since it has predefined sections and prompts, all your information will be captured in the note.
The following is a nursing narrative note template:
1. Patient Information
4. Patient Response
According to the HIPAA Journal, clear and accurate documentation is important in nursing to ensure safe and evidence-based nursing practice. Use these tips to ensure you write your notes well.
Don't wait to write your narrative notes. Even if you feel like you have a million things going on, find time to write the narrative note, preferably as soon as possible.
If you leave it for later, you might forget to record some crucial information. This could be risky for the patients as their attending doctor or a new nurse may miss critical information about their health, thus impeding treatment and healing.
Avoid beating around the bush by jumping directly to what matters. Narrative notes are crucial for communicating essential information about the patient to other healthcare providers.
Quantify information whenever possible and only use objective descriptions where it is impossible. For instance, instead of saying the patient was experiencing extreme pain, you could say their pain level was 9/10.
Ensure that only important information is included and nothing else is included. Strike a balance between being detailed and concise. One of the ways you can ensure this is possible is by collecting all the relevant information about the patients themselves and their illnesses.
Then, write only relevant information in the note. Including unnecessary information will make it harder for readers to scan through and access pertinent information about the patient and their condition.
If you interacted with other health workers to help take care of the patient, please note it down. Doing this is important in ensuring that they can be easily identified when necessary. For instance, if there are any issues of concern, one will know who to reach out to instead of making guesses that could waste time.
If you made a phone call to a specialist for the patient's case, ensure you provided the exact time you made the call, the message you requested, and the responses given. For example, At 2.15 AM, I made a phone call to Dr. Johnson about the patient's elevated blood pressure of 180/120. The doctor advised that I should take 20mg of Lisinopril and monitor the patient's progress.
Providing phone call records ensures a clear record of information that is essential for continuity of care.
Clear communication is vital in healthcare. Using medical terminology provides a standardized way of communicating crucial information about the patient. It helps communicate symptoms, conditions, providers, and interventions. For instance, instead of saying, I took a small sample of tissue for testing, you could say, I did a biopsy.
Medical terms are also important to ensure your notes are easier to read, particularly in a fast-paced medical environment.
Legibility in nursing is important to ensure readers understand the information in the notes. If you are writing by hand, ensure that all your information is readable. You can achieve this by having proper grip and writing slowly. Writing fast is one of the main reasons for messy writing. So take your time to ensure every word can be ready without confusion.
Additionally, ensure that you use proper grammar and punctuation when writing your nursing narrative notes. Effective communication through proper grammar and punctuation helps prevent misunderstanding among the healthcare team attending to the patient.
Ensure you discuss the main issues that brought the patient to the hospital. You must explain this in detail and provide the interventions given. This will show that they actually received the help they needed in the first place.
Once you have addressed this, include other health issues that you identified after examining the patient.
Providing patient care is one of the many duties of nurses. Now, when a patient refuses treatment or medication, that is solely on them. However, refusing to write down that the patient has refused treatment is on you because one would just assume that you failed to offer treatment when you were supposed to.
Writing down the patient's refusal of treatment is important both for legal reasons and to inform other healthcare providers of their decisions. When noting this, provide the exact time the patient refused and what actions you took.
When possible, ensure you use an active voice. In an active voice, the subject performs the actions. For instance, instead of saying the patient was given 500 of paracetamol, you could say I gave the patient 500 mg of paracetamol.
In nursing, professionalism is about providing quality care to patients while demonstrating values like respect, advocacy, and responsibility. It also involves communicating the right way.
Being professional also means using complete descriptions to provide clarity and prevent ambiguity. For instance, instead of saying ‘patient in pain,’ you could say something like; the patient was groaning in pain holding lower abdomen, pain rated at 9/10.
After writing the note, check for grammar, spelling, and sentence structure. Leaving these errors in will undermine the quality of your nursing notes.
Writing a nursing narrative note is an important part of nursing practice as it helps communicate about the patients and all the care the nurses is providing them. A good nursing note must include all the patient information that will help identify them and their condition, assessment, interventions provided, and follow-up actions.
If you need help writing this type of note, writers from our nursing essay writing service can help. Contact us today for more information.
