Here is an example of a clincal finding narrative for SOC
7Jan 12, '13 by paradiseboundRNI 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
0Jan 14, '13 by GrnTea, BSN, MSN, RNI 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.
0Jan 27, '13 by KellT1203Some of my summaries are much longer than this. I cover so much in my narrative. I try not to chart what the OASIS covers already. If there is something I am trying to help the patient with (communtiy resources, order for PT/OT/MSW), if the patient declines I will add this to my narrative. Basically I try to add anything that is not on the OASIS which is discussed in my SOC. This can be A LOT of different things.
0Jan 30, '13 by AnneP726To me, its home care so I start mine with a bit of where they live, high rise elderly housing, 2nd floor apt, ALF, single family home... then their support system, lives with son, daughter visits 2-3x/wk, lives alone w/ elder services...
Then some about the hospitalization with dates, procedures, med changes, stuff you can get from a DC summary. Here at least they use a lot of hospitalists so the PCP often is unaware they were in and this note gets attached to the 485 so it gives him/her some basic info.
Next I add PMH, Sx
And last but not least the basic POC, schedule plan, what you hope to accomplish.
I too only add to, or embellish on, my OASIS note. I worked too long on it and don't wish to repeat myself.