Here is an example of a clincal finding narrative for SOC
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This is a discussion on Here is an example of a clincal finding narrative for SOC in Home Health Nursing, part of Nursing Specialties ... I read a lot of posts asking for help with a narrative so here is an example for a SOC PATIENT...
by paradiseboundRN Jan 12I read a lot of posts asking for help with a narrative so here is an example for a SOC
PATIENT IS 78 Y/O FEMALE POST HOSPITALIZATION FOR EXAC OF COPD. INDEPENDENT PRIOR TO HOSPITAL PMH: COPD, CAD, HTN, ANEMIA, NIDDM. CURRENTLY, A&OX3, VITALS WNL. USES 2L/NC OXYGEN CONTINUOUSLY. DYSPNEA WITH MINIMAL EXERTION. LUNGS SOUNDS DIMINISHED BILAT. NEW NEBULIZER AND RX FOR ALBUTEROL. ADMITS TO STRESS BLADDER INCONTINENCE. POSITIVE BS X4. SHE HAS A 0.5 X 0.5 X 0.2 CM WOUND (SKIN TEAR) ON HER RIGHT ANTERIOR FOREARM. POSSIBLE TAPE BURN. WOUND BED IS BRIGHT PINK WITH NO DRAINAGE. BANDAID APPLIED. FBS 110 TODAY AND COMPLIANT WITH GLUCOMETER AND 1800 ADA DIET .EDEMA: 2+ PEDAL BILATERAL, LEFT INSTEP 28CM, RIGHT INSTEP 26CM. RATES PAIN 2/10 IN BACK DUE TO ARTHRITIS. UNSTEADY GAIT, USES WALKER. INDEPENDENT WITH ADL'S EXCEPT BATHING. LIVES WITH BROTHER WHO IS MAIN CAREGIVER. PLAN TO TEACH COPD DISEASE PROCESS AND MANAGEMENT; TEACH MEDICATIONS, SAFETY, NEBULIZER, HOW TO DECREASE EDEMA. MONITOR WOUND.
Basically you need to write the story. What were they in the hospital for? Medical HX? and then go through this list. I usually chart by exception, meaning that if I didn't mention it, it does not pertain or is normal. I added normals to this example so you could see how its done. All of this assessment data is in the OASIS anyway but most agencies want you to write a narrative. I might have missed something but this is the basics. Hope it helps.
orientation
vitals
lungs
oxygen
exertion level
bladder/bowel
wounds
pain
edema
FBS if diabetic
diet
ambulation
assistive devices
ADLS
support system/CG
new meds (coumadin, insulin)
new DME or equipment
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http://allnurses.com/showthread.php?t=808070©2013 allnurses.com INC. All Rights Reserved.dirtyhippiegirl and Jean Marie46514 like this. -
- Jan 12 by paradiseboundRNI want to add that I had this as a word document and cut and paste according to the patient. Sorry about the caps, but we did all of our documentation in McKessen Horizons in caps.tewdles likes this.
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Jan 13 by Jean Marie46514Great post, this will be so helpful for so many, this is asked about a lot, it seems. THANKS! -
Jan 14 by GrnTeaI would add that if you don't have a form to fill out for your charting by exception, you should put in normal findings in a narrative note. Not to do so leaves the open question: "Did she even look?"
You never want to have the answer to that be, "Gee, I don't know whether she did or not," especially if the reason it's being asked is because of a missed finding that led to harm. Saying, "If I didn't note it, it was normal" will not hold up as any kind of defense. - Jan 14 by paradiseboundRNI agree, but all of the systems assessments are in the OASIS, so the note is supposed to be a summary.
