There are different "formulas" to follow for narrative charting. These will vary facility to facility. A common mnemonic......SBAR.
is an acronym for situation, background, assessment
, and recommendation.
Identify the patient and who is involved. Identify the problem/diagnosis, recent changes.
Review of systems, pertinent medical history (allergies, code status, chronic diseases, and disability), safety/ cultural issues, precautions, labs, medications, mobility status, mental status, next of kin, equipment, tubes, drains, medications, IVs
Plan of care, summary of current condition, catheters, drains, lines, tubes, treatments.
Pending tests, suggestions or requests, physicians’ orders, what is to happen, where, when, and how, to-do items, anticipated changes, and outstanding issues
This thread is old and some of the links might not be active but it is a great thread on documentation.