Anyone know of a website with some narrative notes examples???

I had my first week of clinicals this week and had a hard time getting the narrative notes done..I am a little confused on what I am supposed to be writing and would like to see some examples. If anyone knows where I can find some I would be greatful! :)

[Jo Anne -OLD]

I had my first week of clinicals this week and had a hard time getting the narrative notes done..I am a little confused on what I am supposed to be writing and would like to see some examples. If anyone knows where I can find some I would be greatful! :)

I would like to suggest a book that goes by the name " Charting...Made Incredibly Easy!" by Springhouse.

There's a full line of "Made Incredibly Easy!" books.

Try your local bookstore.

Hope this helps.

[ctyler98]

Thanks, I'll check it out. :)

[jenrninmi, MSN, RN]

Sorry, I'm in my 4th/5 semesters and I don't know what "Narritive Notes" are. We must use a different term. What is it?

[luoonacy]

Is that the same as progress notes?

[kathy_79]

Sorry, I'm in my 4th/5 semesters and I don't know what "Narritive Notes" are. We must use a different term. What is it?

narrative notes is "story " type notes about your pt during your shift. paragraphes that documents your pt condition, your nursing interventions, and outcomes from pt relevant to those interventions. mostly nurses do not use this, it is time consuming, difficult to monitor, you need to write all what is directed to your pt. you need to find policy of nurse progress notes at your facility. as far i know there are dar notes, soap and soapie, and pie.

where i have clinical they use soapie. :)

[jenrninmi, MSN, RN]

narrative notes is "story " type notes about your pt during your shift. paragraphes that documents your pt condition, your nursing interventions, and outcomes from pt relevant to those interventions. mostly nurses do not use this, it is time consuming, difficult to monitor, you need to write all what is directed to your pt. you need to find policy of nurse progress notes at your facility. as far i know there are dar notes, soap and soapie, and pie.

where i have clinical they use soapie. :)

Thanks for the clarification.

[talaxandra]

Nobody where I work cares what style we use, as long as everything's documented. To my mind notes serve two purposes: communication and CYA in case of trouble; I always write them keeping the Coroner's Court in mind, for I am unnecessarily paranoid :)

Reading the definition, I suppose I write in a narrative style; for example:

"Mrs X reported abdominal pain at ! 2300; on return to bedside at 2320 she was sleeping. Pain reported again at 0100 - paracetamol 1g given with good but transient effect: at 0330 Mrs X reported severe pain (7/10) radiating out from the PEG site. Difficult historian, but pain seems to be sharp and constant, exacerbated by movement, touch, deep breathing/coughing, compounded by anxiety/fear of pain worsening. Abdomen lax, generally tender (more so over LUQ), diminished bowel sounds; vital signs unremarkable, afebrile.

"PEG feeds ceased pending unit review; covering RMO Y contacted, then notified at 0630, when Mrs X began to cry out - unable to rate or describe pain or i/how it had changed. Reviewed by RMO Y as above - ECG performed, U&E/FBE/lactate/CK + troponin taken (results pending), morphine 2mg IV given at 0655, with no effect at time of report."

(there was also a description of care given overnight - eg pressure care and skin integrity, mouth care and condition of oral mucosa - and a plan for the next shift)

I agree with Kathy that they can take longer; if not done well they can also make it hard to find the relevant information - some people write acres of waffle, with the germane information hidden.

I have a line break ('paragraph' makes it sound bigger than it is) for each topic, so it's not only visually appealing (rather than a big block of text) but it's easier to find specific inormation.

I like this style because there's a little more flexibility about where things can go than in some other styles - urine output can go with input, in it's own category with other output, in conjunction with description of fluid status etc

I also like having the opportunity to write about the patient's day chronologically if necessary - sometimes the order of things is important.

We only have to write notes on admission, the AM (for all patients) and with exceptional events (including unstable patients). I also write notes on a patient's first admission, post-op or post-procedure night. If I had to write eight sets of notes every night I might be less verbose, but I doubt it :)

Sorry I can't help the OP with a book or style guide.

[Jo Anne -OLD]

Nobody where I work cares what style we use, as long as everything's documented. To my mind notes serve two purposes: communication and CYA in case of trouble; I always write them keeping the Coroner's Court in mind, for I am unnecessarily paranoid :)

Reading the definition, I suppose I write in a narrative style; for example:

I agree with Kathy that they can take longer; if not done well they can also make it hard to find the relevant information - some people write acres of waffle, with the germane information hidden.

I have a line break ('paragraph' makes it sound bigger than it is) for each topic, so it's not only visually appealing (rather than a big block of text) but it's easier to find specific inormation.

I like this style because there's a little more flexibility about where things can go than in some other styles - urine output can go with input, in it's own category with other output, in conjunction with description of fluid status etc

I also like having the opportunity to write about the patient's day chronologically if necessary - sometimes the order of things is important.

We only have to write notes on admission, the AM (for all patients) and with exceptional events (including unstable patients). I also write notes on a patient's first admission, post-op or post-procedure night. If I had to write eight sets of notes every night I might be less verbose, but I doubt it :)

Sorry I can't help the OP with a book or style guide.

I truly enjoy reading your posts.

Are you also a writer?.

[talaxandra]

That's so lovely, Jo Anne, thank you :imbar I'm glad you like my notes - after I posted and saw how much I'd written I was worried I'd bore every poor person who followed the thread - I'm glad that wasn't the case for at least one member :)

Every year I compete in the NaNoWriMo (http://www.nanowrimo.org) - the aim is to write a 50,000 novel in the month of November: if you manage that then you win. My novels aren't great - the first year I wrote a strongly-autobiographical work about a nurse who decides to destroy her charge nurse - it was very therapeutic and only significantly libellous :chuckle Last year I tried a romance, and I discovered that writing one that doesn't suck is no easy feat!

Aside from that the only writing I do (apart from patient notes!) is school-related. But I read a lot (I average a novel every other day and two non-fiction books a week, more when I'm not also doing school reading), and I talk a lot. Language is my friend!

I'm really fortunate - I have a fly-paper memory, so I tend to remember what I see, hear and read on the first exposure, and I have a large vocabulary, so I sound smarter than I am

Is that flag for me, or are you One of Us? (I think Australians need a secret handshake, or at the very least a portable roll of thunder, to be unfurled at the appropriate moment!)

[Jo Anne -OLD]

That's so lovely, Jo Anne, thank you :imbar I'm glad you like my notes - after I posted and saw how much I'd written I was worried I'd bore every poor person who followed the thread - I'm glad that wasn't the case for at least one member :)

Every year I compete in the NaNoWriMo (www.nanowrimo.org) - the aim is to write a 50,000 novel in the month of November: if you manage that then you win. My novels aren't great - the first year I wrote a strongly-autobiographical work about a nurse who decides to destroy her charge nurse - it was very therapeutic and only significantly libellous :chuckle Last year I tried a romance, and I discovered that writing one that doesn't suck is no easy feat!

Aside from that the only writing I do (apart from patient notes!) is school-related. But I read a lot (I average a novel every other day and two non-fiction books a week, more when I'm not also doing school reading), and I talk a lot. Language is my friend!

I'm really fortunate - I have a fly-paper memory, so I tend to remember what I see, hear and read on the first exposure, and I have a large vocabulary, so I sound smarter than I am

Is that flag for me, or are you One of Us? (I think Australians need a secret handshake, or at the very least a portable roll of thunder, to be unfurled at the appropriate moment!)

The flag is for you.

I was born in Puerto Rico, but I have lived, here, in America for 20+ years.

I just admire your eloquence....

My 9 y.o. has your gifts as well. She has a very high IQ and difficult concepts, ideas, come easy to her.

She was "labeled" (for lack of a better term) a gifted child when she was 3.

When she began to read and play the piano on her own, I knew she was extra-special. She wants to be an artist someday and absolutely loves Van Gogh, Monet, Picasso.

But enough bragging!

I will check-out the site you cited.

TTFN!

Jo

[talaxandra]

A flag and a koala - I'm spoiled :)

Unlike your daughter I am not artistic - that gift went to one of my sisters, and facility for music passed all of us by. If you don't like 'labelled' (Aussie spelling!) how about 'identified as gifted'?

I had every advantage, including going to a school that streamed me into their high achieving class, and coasted through life. If it hadn't been for the accident of me discovering nurse I could have ended up like one of those MENSA people - smart and working as a garbo (I'm saying people who belong to MENSA are necessarily underachieving, just that I would have been :)). It's hard to have a sense of accomplishment without the effort.

And now that I re-read that it sounds as though I'm predicting a pointless, wasted life for your daughter - I'm not, I swear! I get the feeling that you (unlike my parents) will take a hand in guiding your daughter so that she doesn't coast :)

D**n, and there you were, liking me. I am very aware that I am where I am through luck - I think our society minimises the impact luck has on our lives (the British philosopher Alain de Botton has written a fantastic book, "Status Anxiety" which in part deals with this topic, which is the only reason I'm able to articulate it). I can take pride in the kind of person I am, and the kind of nurse I am (she says, finishing off this post instead of weighing the renal patients before breakfast!), but the gifts I have are accidents, not proof of my innate superiority. Do you like me again?

(Paranoia wars with insecurity - who will win?!)