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- by meluvsquki Dec 30, '12New nurse here four months into orientation...
I've been struggling with writing my narratives. Since I've been so used to banging out care plans in nursing school, it's been much more difficult than it should be to write my nursing notes or narratives.
It also doesn't help that I've had 7 different preceptors and everyone has their own style of writing their note.
Some people are very brief, some people write paragraphs.. Some people want me to write out my shift assessment, describe the patients as how I found them when I received them...even though I've already charted in the shift assessment flowsheet....
How do you guys write your narratives? Also, is there a good way to practice writing them?
- Dec 31, '12 by CP2013There are 7 different ways as you have seen and a million more. I was always told to be as thorough and yet succinct as possible because when called to court, that note is my only saving grace (should it happen).
Usually I see them with shift assessment, vitals, how patient was received. Then an off going narrative with vitals for the next shift to CYA and ensure nothing will fall back on you.
That's just how I have seen it done in general, but there are a dozen and one ways to do them and you have to do what you feel most comfortable with.
Talk to your unit manager about any specific policies in place regarding data and info that should or shouldn't be included in a narrative.
Also, better to double chart that under chart. if assessment was negative for any significant findings just say that, or chart by exception and only put the positive assessment findings in your narrative note. Use a SOAP method (subjective, objective, assessment, plan) if that is easiest for you. Good luck!
- Jan 2 by GrnTeaOne of the nicest things a doc ever said to me was that he loved my nursing notes. He said when he read them he could see what the patient looked like and what was going on. Personally, at the time I didn't think that was so exceptional-- I mean, isn't that WHY we write nursing notes, to communicate patient status, treatment, and results? Well, yes, in part.
Medical records serve many purposes: communication between disciplines and shifts, documentation that supports billing, research data, teaching tool, legal, risk management, licensing and accreditation processes, staff evaluation...
If knowing that is helpful, you can see your way clear to serving all these needs by writing a comprehensive note that lets the reader know how important your care is. Think about all those people reading your notes down the road-- tomorrow, next month, next year, next decade. What do they need to be able to see with your eyes? Hear with your ears? Feel with your touch? See and understand about your actions?
- Jan 3 by HouTxWhat is your organization's policy? Do they use a specific format? Be sure to review any P&P/guidelines and make sure you are complying with them. I'm actually surprised that you're still doing so much since everyone is converting to electronic charting - which is mostly 'charting by exception'. Not saying it's better - just different.