Narrative Note Example Nursing

Narrative Note Example Nursing

A narrative note is one type of documentation that you can use for an incident report. An incident report is a way to document anything that happens that is outside of normal operations. Any incident could be a risk management issue, but only if the event was foreseeable and preventable. An incident report should include the following information:

Incident description: what happened?

Why it happened: why did it happen? Could it have been prevented? If so, by whom or what would have prevented it?

The next sections will help you write your own nursing narrative with clarity. Here are some tips for writing a thorough and professional nursing narrative note:

A narrative note is one type of documentation that you can use for an incident report.

A narrative note is one type of documentation that you can use for an incident report. A narrative note describes what happened but not in the same way as a progress note. It’s written in story form and includes details about the patient’s condition, treatment, and response to treatment. You’ll also need to write down how you assessed the patient, what findings you recorded, any interventions performed and their outcomes.

If you’re working on an incident report in healthcare or nursing homes, this type of documentation may be required by your employer or facility when there has been an unexpected event that could affect patient safety or operations.

An incident report is a way to document anything that happens that is outside of normal operations.

An incident report is a way to document anything that happens that is outside of normal operations. The goal of an incident report is to capture, analyze and learn from incidents so they can be prevented in the future. Incidents are things that go wrong and can be caused by many things: people, processes or equipment. In some cases an incident may have been caused by all three elements working together (e.g., a machine breaks down prompting someone who knows how to fix it but doesn’t have any spare parts on hand).

Any incident could be a risk management issue.

Any incident could be a risk management issue, whether it is a serious or minor event, and whether it involves you or someone else.

  • Learning experience: The organization needs to learn from incidents so that they can prevent them from occurring again in the future.
  • Legal issue: Incidents can be a legal issue if they result in harm to patients or staff members, violate laws that apply to healthcare organizations (such as HIPAA), cause liability concerns for the organization, or have other implications for litigation against the organization.
  • Quality improvement issue: If an incident occurs due to poor quality of care practices at any level (e.g., nursing care plan documentation), then improving those practices might reduce future risks and improve patient outcomes.
  • Performance improvement issue: Some organizations use nursing incident reports as part of their performance appraisal process so that nurses can identify areas where they need improvement based on how often these types of incidents occur within their unit/team/department over time

An incident report is also called an accident report or an occurrence report.

You will likely encounter the terms “incident report” and “accident report” when dealing with insurance claims and hospital administration. An incident report is also called an accident report or an occurrence report. While these terms may seem interchangeable, they do have subtle differences that you should be aware of.

  • What is an incident? An incident is something that occurs unexpectedly, either on its own or as a result of another action (i.e., you drop your phone and it breaks).
  • What is an accident? Accidents are unintended outcomes caused by mistakes or errors in judgment that lead to unintended consequences, often resulting in harm to yourself or others (i.e., walking into a glass door).
  • What is an occurrence? Occurrences usually involve events that cannot be controlled by humans but which can still cause harm (i.e., earthquakes).

An incident report should include the following information.

An incident report should include the following information:

  • What happened. Be as specific as possible, including all details you can recall.
  • When it happened. Include the date and time of occurrence if known.
  • Where it happened. Be sure to include both a general location (city, state) and more specific details (floor number, room number). If an event occurred in multiple locations over a period of time or is still ongoing, identify each location separately with its own heading under “Where.”
  • Who was involved in the event(s)? List everyone involved, even if they were only witnesses or bystanders who didn’t take part in any way—this will help keep track of people’s interactions during an ongoing emergency situation such as a fire drill or evacuation due to a bomb threat on campus.)

Include any other relevant information about those involved: for example: “Mrs Smith was injured when she fell down stairs while trying to evacuate building A2 after being told there was smoke coming from somewhere else nearby.” This may seem unnecessary but it’s important if someone has been harmed because she didn’t follow proper protocol; we need evidence that someone did something wrong!

Also include identifying information such as names (first), job titles/positions within organization), addresses/contact info where available.”

An incident report should be written in the third person, meaning you should avoid using pronouns like I and we.

An incident report should be written in the third person, meaning you should avoid using pronouns like I and we. Instead of writing “I was doing a check on my patient when he suddenly became unresponsive,” you should write “When the nurse checked on her patient, he became unresponsive.”

In addition to avoiding personal pronouns, use the active voice instead of passive voice. Passive voice sentences start with an action verb and then contain an object followed by a form of “to be.” In contrast, active voice sentences begin with the subject performing an action: “The nurse checked on her patient.”

An incident report should answer these questions.

An incident report should answer these questions:

  • What happened?
  • Who was involved?
  • Where did it happen?
  • When did it happen (date, time)?
  • Why did this occur?
  • How was the situation handled?

This incident report answers all of these questions. It begins with a brief description of the event and ends with a list of resources for further reading.

Here are some tips for writing a thorough and professional nursing narrative note.

  • Use active voice. Active voice makes the narrative note more interesting and easier to read. It also makes it easier to write, since subject matter is clearly stated in the sentence (i.e., “The patient was alert and oriented.”).
  • Write proper grammar. Grammatical errors are distracting and can make you appear unprofessional, so proofread your notes several times before submitting them for review by your instructor or supervisor. You may want to ask someone else (such as a friend or family member) who has good writing skills to proofread your work as well.
  • Be consistent with format and tone throughout the entire nursing narrative note, from beginning to end.*

There are many examples of nursing narrative notes online but you may want to look at some of these before you begin writing your own reports so that you have a better sense of what makes one good or incomplete.

There are many examples of nursing narrative notes online but you may want to look at some of these before you begin writing your own reports so that you have a better sense of what makes one good or incomplete.

Nursing students should consider looking at examples from other fields such as medicine, psychology and pharmacology. This will give them an idea of how different professions handle their workflows and documentations.

Writing your narrative with clarity will help others understand exactly what happened without asking many questions.

  • Use active voice.
  • Be clear and concise in style.
  • Use a professional tone, avoiding slang and jargon.
  • Consistently format your narrative notes using the template provided below:
  • Brief history of present illness (HPI) – in chronological order as appropriate for the situation
  • Assessment/diagnosis – describe findings from assessment in layman’s terms; include pertinent lab results, imaging studies, etc.; avoid abbreviations or acronyms unless these are commonly used by nurses within your region or healthcare system; do not make any conclusions about the patient’s condition or plans for care at this point—these should be reserved until after you have developed your plan of care
  • Plan of Care – describe what happened next in terms of interventions given to address immediate concerns along with any additional steps taken to ensure safe transfer out of acute care setting into long-term follow-up if applicable (e.g., discharge instructions given); include specific medications/vaccinations administered during hospitalization; also record if POC devices were used at any point during this encounter

After you’ve completed writing your nursing narrative note, it’s important to get it reviewed by your supervisor or manager before sending it out. They will be able to help you with any grammar mistakes and other errors so that the report is clear and concise.

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