Sample Narrative Nursing Note

Narrative nursing notes are used for patient care documentation. They can be either written or verbal, and they provide a detailed account of what happened with a specific patient during their hospital stay. In addition to documenting the status of the patient at regular intervals throughout the day, narrative nursing notes also include information about actual interventions that were carried out and any follow-up appointments or tests that need to be scheduled after discharge from the hospital. This sample narrative nursing note includes all of these elements:

Report of the patient’s condition (status report).

The patient’s name is Jane Doe, age 45. The patient has been diagnosed with depression and anxiety. She has no known allergies to medication or adverse reactions. Her vital signs include a temperature of 98.3, pulse of 85, and blood pressure of 120/80. She is awake and alert with normal orientation to person, place and time (date). No history of alcohol use was reported by the patient or family members in this visit; however it may be due to denial on behalf of the patient due to her mental health issues.

The nurse assessed that Jane Doe has normal general appearance: she appears well nourished; her skin tone is pink without lesions; there are no signs of acute infection such as fever, rashes or generalized inflammation; there are no abnormal body odors present such as excessive sweating due to anxiety attacks etcetera…

Assessment of the patient’s condition.

• The patient’s condition is stable

This refers to when a patient’s status has remained unchanged for a time period. For example, if you were assessing a patient in the ICU who had been on mechanical ventilation for four days and the patient was still being treated with the same level of care as they have been receiving since admission (i.e., no changes in treatment), then this would be considered stable.

• The patient’s condition is improving

If there have been significant improvements in your patients’ conditions or if they are getting closer to being discharged from your facility or hospital, then these are examples of how their statuses could be considered improving.

• The patient’s condition is unchanged

If your patients’ statuses remain unchanged after a certain amount of time has passed (for example, two weeks), then this would be considered unchanged. This can mean that nothing has changed since you last assessed them or even that it hasn’t changed since their admission date/time/etc..

Actual nursing interventions that were carried out.

• Nursing intervention:
• Outcome of nursing interventions:
• Reason for nursing interventions:
• Patient’s response to intervention:

Evaluation of the patient’s outcome.

The patient’s condition has improved. The patient’s condition is unchanged from baseline. The patient’s condition has worsened since the last visit and they are now showing signs of __________.

• This narrative includes only relevant information and can be used in a PDF format or as a Word document.

The following sections may be included:HistoryExaminationLaboratory results

This is a sample narrative nursing note.

Takeaways

This is a sample narrative nursing note.