OB narrative nursing notes

[tsm007]

Newbie looking for advice with narrative nursing notes. I did hardly any in school so I have little practice at them. Most of the nurses here do a narrative nursing note as part of hourly rounding. I'm trying to figure out what types of things I should be putting there and wording for charting it. I don't want to be putting irrelevant stuff just to be charting something. If you use narrative nursing can you give me some examples of things you would chart on postpartum mom and baby or laboring mom for that matter too?

[everthesame, LPN, LVN]

For just an hourly round note, I chart what they are doing and whether or not they have any needs. If they do, I state what it was/how it was met. Some examples:

Patient sitting up in bed talking with visitors. Denies any needs at present.

Perineal cold packs given per pt request.

Pt resting in bed w/ eyes closed. Appears to be sleeping.

For baby I would put something like "Baby remains in mom's room, sleeping in crib." Or "Baby being held by mom/dad/visitor."

Just a quick little note to indicate you laid eyes on the patient.

Our current charting system has boxes you can tick off on an hourly rounds screen plus it has a narrative field so we can chart stuff that may not be addressed by a tick box.

I don't work labor room so I can't speak to what they would be charting hourly.

[tsm007]

For just an hourly round note, I chart what they are doing and whether or not they have any needs. If they do, I state what it was/how it was met. Some examples:

Patient sitting up in bed talking with visitors. Denies any needs at present.

Perineal cold packs given per pt request.

Pt resting in bed w/ eyes closed. Appears to be sleeping.

For baby I would put something like "Baby remains in mom's room, sleeping in crib." Or "Baby being held by mom/dad/visitor."

Just a quick little note to indicate you laid eyes on the patient.

Our current charting system has boxes you can tick off on an hourly rounds screen plus it has a narrative field so we can chart stuff that may not be addressed by a tick box.

I don't work labor room so I can't speak to what they would be charting hourly.

Thank you. I have been looking at other nurse's notes too and jotting things down on a cheat sheet when I like how they word something or I notice something I should be charting that I am not.