I 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.
FBS if diabetic
new meds (coumadin, insulin)
new DME or equipment