Here is an example of a clincal finding narrative for SOC

I want to add that I had this as a word document and cut and paste according to the patient. Sorry about the caps, but we did all of our documentation in McKessen Horizons in caps.

Great post, this will be so helpful for so many, this is asked about a lot, it seems. THANKS!

I 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.

I agree, but all of the systems assessments are in the OASIS, so the note is supposed to be a summary.

Some 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.

Love your narrative, it paints a great picture of why you're admitting the patient, however I don't believe areas that are covered in the oasis need to be repeated.

I wholeheartly agree but I see most nurses doing it anway!

I would add any home enviorment issues, safety in home issues, barriers to education and learning, if the patient has and can afford all medications... but that's a a great narative you wrote!

To 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.

The Oasis covers mostly what patient is able to "safely" do, which can be confusing. The narrative covers what the patient actually does. Good narrative. It's really ridiculous the amount of charting home health nurses have to do.

Now a note is needed as well ?? Twenty plus pages of oasis and they still want the nurse to spend more time doing paperwork. This is why we need a national militant labor movement in this country. It takes real moron to tell bedside nurses better care will occur if you increase the paperwork some more. America has the most costly care in the developed world with half the outcomes. More paperwork is the key to better care. Sound stupid ??

Yea, it does.

Computerized charting was supposed to free up nursing to spend more time at bedside, but as usual we have been and continue to allow our practice to be totally sabotaged. Nurses are either running around like chickens with their heads cut off, or glued to the computer. This is the new normal. I've had older patients patients notice and comment on the change they've seen in nursing. :/

A friend of mine is an RT that does home care, vent set ups, assessments, follow up and CPAP's, makes more than me an hour and has almost no paperwork. She says her paperwork is inconsequential to her day/ like super quick in a couple minutes per patient, not even an issue. So respiratory therapy in the home has figured out how not to strangle the therapists, but nursing can't?

(Sigh...)