grannypatches. . .most large facilities have a policy and nursing procedure that defines exactly how they want the nurses to document the care they give. the next time you are in your clinicals and have a chance, ask about the charting policy and to see the policy and procedure manual on this (it may be computerized these days). sometimes the nurse educator of the facility will have this information as well and may even have a self-learning packet they give to orientees (new nurse employees) that they would be willing to give you to help you out with learning this.
from portable rn: the all-in-one nursing reference
, 3rd edition, by lippincott, williams & wilkins, page 674. . ."narrative charting is a straightforward chronological account of the patient's status, the nursing interventions performed, and the patient's response to those interventions. documentation is usually included in the progress notes and is supplemented by flow sheets. the joint commission on accreditation of healthcare organizations (jcaho) standards require all health care facilities to set policies on how frequently patients should be assessed. document patient assessments as often as your institution requires and more frequently when you observe any of the following:
- change in the patient's condition
- patient's response to a treatment or medication
- lack of improvement in the patient's condition
- patient's or family member's response to teaching
document exactly what you hear, observe, inspect, do , or teach. include as much specific, descriptive information as possible. always document how your patient responds to care, treatments, and medications and his progress toward the desired outcome. also include notification to the physician for changes that have occurred. document this communication, the physician's response, new orders that are followed, and the patient's response.
you can organize your notes by using a head-to-toe approach or by referring to the care plan and documenting the patient's progress in relation to the plan and any unresolved problems. regardless of the way you organize your narrative note, be specific and document chronologically, recording exact times."
this sample of narrative charting is given on page 675 (kind of hard to show the actual physical formatting, but i think you're more interested in the actual wording, right?):
"11/26/06 2255 patient 4 hr postop; awakens easily, oriented x 3 but groggy, incision site in front of l ear extending down and around the ear and into neck--approximately 6" in length--without dressing. no swelling or bleeding, bluish discoloration below l ear noted, sutures intact. jackson-pratt drain in l neck below ear with 20 ml bloody drainage measured. drain remains secured in place with suture and anchored to l anterior chest wall with tape. pt. denied pain but stated she felt nauseated and promptly vomited 100 ml or clear fluid. pt. attempted to get oob to ambulate to bathroom with assistance, but felt dizzy upon standing. assisted to lie down in bed. voided 200 ml clear, yellow urine in bedpan. pt. encouraged to deep breathe and cough qhr, and turn frequently in bed. lungs sound clear bilaterally. antiembolism stockings applied to both lower extremities. explanations given regarding these preventive measures. pt. verbalized understanding.----bridget smith, rn
2300 pt. continues to feel nauseated. compazine 1 mg iv.----bridget smith, rn
2335 pt. states she's no longer nauseated. no further vomiting. rating pain in incisional areas as 7/10, on a scale of 0 to 10. medicated with morphine 2 mg iv.----bridget smith, rn
2355 pt. states pain as 1/10. demonstrated taking deep breaths and coughing effectively.----bridget smith, rn"
lynda juall carpenito has this to say about narrative charting:
"progress notes should contain. . .unusual events or responses, or significant observations or interactions. . .a good rule to follow whenever information comes to the attention of the nurse, which if known by the attending physician would cause the physician to write new medical orders or to cancel or elaborate on existing orders or to discontinue orders, is to verbally communicate the information to the physician. in addition, the nurse should record the information and the notification of the physician in the progress notes. for example, if the results of a neurovascular assessment were. . .abnormal, the nurse would record. . .it [in] an. . .explanatory progress note." (nursing care plans & documentation: nursing diagnoses and collaborative problems, 3rd edition, pages 28-29)
now, i realize that as an lpn, you won't necessarily be responsible for notifying doctors if you work in an acute hospital setting, but if you work in ltc as a charge nurse you will, so you need to know this information.
hope you find that helpful. when i was working i used to make sure i had copied all the doctors orders for labs, diet and treatment onto my "brains" (report sheet). when i charted, i generally started out by writing my head to toe physical assessment of the patient followed by attention to the various doctors orders and how they were being carried out. as i got more experienced i was able to include some of that with the physical assessment as i was writing it up. i always charted observation of iv sites, any tubes or drains and the amount and color of what was draining out of them, dressings or incisions and the amount and color of any drainage, if the patient was getting oxygen, the patients activity (walking, ambulated with one or two assistants, being turned, sitting up in a chair, had no movement on one side of the body as in stroke patients, sleeping) and how they were accomplishing their toileting. any major problems that you know the patient to have should be addressed as factually
as you can write them. and, factuality is usually the challenge of documentation. some words just include our own bias and we have to be careful of that. you will find that over time you will develop a regular way of charting, a format of your own, that you won't deviate that much from. this is a career long evolution. you can also download and use the student clinical report sheet for one patient
that is attached at the end of this post to help you with organizing a head to toe assessment.
here are some sites where there are other samples of narrative charting and other information about nursing documentation: