Narrative Nursing Note Example
A narrative note is a written form of communication that provides information about the professional nursing care rendered to a patient. It may also include notes about how this care was given, what changes were made in treating the patient, and other relevant details. The most common use for narrative notes is to provide a personal account of events that transpired during a patient’s hospital stay or outpatient treatment. A well-written narrative note can help nurses keep their own records organized and make sure they don’t miss anything important when it comes time to write up an incident report as part of an internal review or external audit.
When is a Narrative Note needed?
A narrative note is required when you are documenting a patient’s response to treatment, their condition, their progress or response to therapy.
Where to Write a Narrative Note?
Where else can you write a narrative nursing note?
- On a patient’s medical record. In this case, it will be at the very beginning of their clinical history section and will include information about their presentation and condition upon presentation to the ER or hospital.
- In your own personal medical records (if you have access to them). This can be helpful if you want to look back on previous cases that were similar in nature to your current one so that you can compare notes in order to learn from what happened previously and make better decisions in the future.
- On a nurse’s shift report which provides an end-of-shift recap of what happened during that shift and any notable events or issues/concerns/trends seen throughout it. These are often discussed among other staff members at morning huddles or before shifts begin (and sometimes even after shifts have ended) as well as being used by management when making staffing decisions moving forward into future days/weeks/months(or years).
How to Write a Narrative Note?
Writing narrative notes can be a bit more challenging than your typical nursing note. It’s important to remember that the purpose of a narrative note is not just to convey information but also to tell a story. A good narrative nurse will write in an organized manner, using appropriate formatting and consistent terminology, but also use active voice and friendly tone throughout the entire note.
What does this mean? Well, first off: don’t be afraid to experiment with different styles—you might find that you like one better than another! In general though, it’s best practice to keep things simple and easy-to-read. It doesn’t matter how fancy your handwriting is if no one else can understand what it says! Here are some other tips for writing an effective narrative:
Review the narrative note example and use this checklist as a guide in writing your narrative nursing note.
The narrative note is a written record of the patient’s condition and progress. It may be written at any time while the patient is in the hospital or outpatient setting, but it must be completed within 24 hours of discharge. The chief resident reviews each nurse’s narrative notes every morning during rounds so that they can discuss changes in patients’ conditions and make decisions about care plans.
The following checklist can help you write your own narrative nursing notes:
- Document all clinical data relevant to your patient’s care.
- Include assessment findings, interventions, and outcomes related to each clinical problem identified for the patient’s care.
- Identify any potential problems requiring additional action by other healthcare providers (i.e., physicians or subspecialists).
- Provide information about established goals for care (e.g., discharge planning), which may include discharge instructions for patients who will be discharged from an outpatient setting (e.g., home health agency).
By now, you should be aware of when and where to write a narrative nursing note. However, if you are still unsure of how to start writing one, there are tips on how to do it here. In summary, always keep your audience in mind when writing this type of note so that the message is clear and not confusing for them.