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Here is an example of a clincal finding narrative for SOC

Home Health   (40,032 Views 16 Comments)
by paradiseboundRN paradiseboundRN (New Member) New Member

paradiseboundRN has 11 years experience and works as a Home Health Nurse.

9,935 Visitors; 358 Posts

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I read a lot of posts asking for help with a narrative so here is an example for a SOC

PATIENT IS 78 Y/O FEMALE POST HOSPITALIZATION FOR EXAC OF COPD. INDEPENDENT PRIOR TO HOSPITAL PMH: COPD, CAD, HTN, ANEMIA, NIDDM. CURRENTLY, A&OX3, VITALS WNL. USES 2L/NC OXYGEN CONTINUOUSLY. DYSPNEA WITH MINIMAL EXERTION. LUNGS SOUNDS DIMINISHED BILAT. NEW NEBULIZER AND RX FOR ALBUTEROL. ADMITS TO STRESS BLADDER INCONTINENCE. POSITIVE BS X4. SHE HAS A 0.5 X 0.5 X 0.2 CM WOUND (SKIN TEAR) ON HER RIGHT ANTERIOR FOREARM. POSSIBLE TAPE BURN. WOUND BED IS BRIGHT PINK WITH NO DRAINAGE. BANDAID APPLIED. FBS 110 TODAY AND COMPLIANT WITH GLUCOMETER AND 1800 ADA DIET .EDEMA: 2+ PEDAL BILATERAL, LEFT INSTEP 28CM, RIGHT INSTEP 26CM. RATES PAIN 2/10 IN BACK DUE TO ARTHRITIS. UNSTEADY GAIT, USES WALKER. INDEPENDENT WITH ADL'S EXCEPT BATHING. LIVES WITH BROTHER WHO IS MAIN CAREGIVER. PLAN TO TEACH COPD DISEASE PROCESS AND MANAGEMENT; TEACH MEDICATIONS, SAFETY, NEBULIZER, HOW TO DECREASE EDEMA. MONITOR WOUND.

Basically you need to write the story. What were they in the hospital for? Medical HX? and then go through this list. I usually chart by exception, meaning that if I didn't mention it, it does not pertain or is normal. I added normals to this example so you could see how its done. All of this assessment data is in the OASIS anyway but most agencies want you to write a narrative. I might have missed something but this is the basics. Hope it helps.

orientation

vitals

lungs

oxygen

exertion level

bladder/bowel

wounds

pain

edema

FBS if diabetic

diet

ambulation

assistive devices

ADLS

support system/CG

new meds (coumadin, insulin)

new DME or equipment

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paradiseboundRN has 11 years experience and works as a Home Health Nurse.

9,935 Visitors; 358 Posts

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.

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1 Like; 14,763 Visitors; 470 Posts

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

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7 Likes; 13,722 Visitors; 11,114 Posts

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.

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paradiseboundRN has 11 years experience and works as a Home Health Nurse.

9,935 Visitors; 358 Posts

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

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KellT1203 has 7 years experience and works as a Med/Surg RN.

8 Likes; 5,829 Visitors; 197 Posts

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.

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635 Visitors; 3 Posts

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.

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paradiseboundRN has 11 years experience and works as a Home Health Nurse.

9,935 Visitors; 358 Posts

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

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AMN74 has 26 years experience and works as a RN.

4,246 Visitors; 124 Posts

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!

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AnneP726 has 3 years experience and works as a 3-11 RN, home care.

1,226 Visitors; 17 Posts

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.

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LaRN works as a Home Health- RN.

8,959 Visitors; 272 Posts

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.

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23 Visitors; 1 Post

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.

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