Narrative Charting

aaa rn, RN · Jun 19, 2007

Hi Grannypatches...Wow, I can't believe how archiac some nursing programs are. I've worked two sites that expected narrative charting. One employer expected us nurses to use DAIR charting, The other, SOAIP charting--both have similarities.

D = DATA. What did you hear and what do you know to be true (empirical evidence garnered thru the five senses and known facts).

A = ASSESSMENT. So, as a nurse, what did you think of the above data?

I = INTERVENTION. So, what did you do about the situation?

R = RESPONSE. How did your patient respond to your intervention?

S = SUBJECTIVE: what did the patient say?

O = OBJECTIVE: What are the known facts and what is the empirical info?

A= ASSESSMENT: See Above

I = INTERVENTION; See Above

P= Plan: What is the next step?

Using the two templates, for example, the narrative would read something like this:

Mary Smith c/o HA. States she has tried to relax but the headache is getting worse.

Mary Smith grimaces as she talks. MAR with PRN Tylenol Q 6 hrs- HA.

Mary Smith has had a HA x 2hrs, could benefit from prn Tylenol.

Provide pt with 500 mg Tylenol.

Response: Effective or Plan: F/u with Tylenol results in half hour, contact attending if no relief.

Granted, this scenario is simplistic, but I hope it helps. Good luck.

Daytonite, BSN, RN · Jun 19, 2007

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.

Ladies & gentleman of the jury, I present...the nursing documentation

grannypatches, BSN, LPN, RN · Jun 22, 2007

Thank you for your very helpful suggestions. It will help me a lot. I have been hearing that narrative charting is not used much anymore but our program requires it. Thanks so much your help...

Daytonite, BSN, RN · Jun 22, 2007

grannypatches said:
Thank you for your very helpful suggestions. It will help me a lot. I have been hearing that narrative charting is not used much anymore but our program requires it. Thanks so much your help...

I know that depending on where you work many are likely to work with check off sheets and do charting by exception. These forms were developed as time saving strategies for nurses. However, if you do chart with those kinds of forms there is usually still a place for a narrative note. No matter how extensive these check off forms are, they can't include everything. There are always going to be instances of things that are going to need to be narratively written--always. Not to instill any fear in people, but I've attended a lot of legal seminars for nurses and one thing that was always stressed is to keep in the back of your mind the idea that if you ever have to sit on a witness stand what you are putting on that form, or fail to put on it, is preserved forever and tells what you observed (or didn't observe) and did (or didn't do) for that patient. A year from today you won't remember the details, but what you put in the chart will still be there to tell the story for you.

Thoroughness will never do you wrong. When I worked with check off forms, as I went down the form and realized there was something I needed to expand about in one particular section, I stopped and went immediately to the narrative section and did some narrative charting before returning back to where I left off on the check off part of the form. If I ever remembered something that i had forgotten to chart I made a late entry.

momathoner09, BSN, MSN, APRN · Jun 22, 2007

Not sure if this will help but I make this mistake all the time and have been really working this semester (3 of 5) to correct it..

If your pt c/o of something, you have to have an intervention for it.

For example: Pt. c/o SOB. Head of bed elevated. Respiratory paged.

Obviously you can only write interventions within your scope. My instructors have repeatedly told me that if the pt c/o of something (pain, HA,SOB, etc) and we don't do anything (or we do something and don't document it) then it looks bad if it ever gets into a lawyers hands. Hope this helps some ?

vashtee, RN · Jun 22, 2007

In addition to the above good advice, I would ask your clinical instructor for examples of GOOD narrative charting to use as examples. Another one of my fellow students was having a lot of difficulty with narrative charting, and so I made photo copies of mine as examples for him to work with, and our instructor was MUCH happier with him thereafter.

VickyRN, MSN, DNP, RN · Jun 30, 2007

Here is a head-to-toe narrative charting template that I developed for my first semester RN students last semester:

2/12/2007 0800. 86 y.o. Male admitted 2/1/07 for left cva. Vs 37.4° c, hr 97, rr 22, bp 140/76. Alert and oriented x 4; denies any pain or distress. Perrla. Responds appropriately to verbal stimuli; no slurring of speech. At risk for aspiration related to dysphagia; on thickened dysphagia diet. Feeds self with assistance. Skin acyanotic with loose turgor. Mucous membranes moist and pink. Negative jvd. Respirations even, unlabored. Breath sounds clear to auscultation throughout all lung fields. (if your patient is on o2, make sure you record the o2 rate and delivery system here, along with pulse ox readings). Apical pulse regular rate and rhythm; s1, s2 noted. Abdomen soft & nondistended with bowel sounds active in all 4 quadrants. Pink nailbeds with capillary refill less than 2 seconds in all extremities. Peripheral pulses palpable in all extremities. Moves all extremities. Hand grips unequal: strong on right, weak on left. Left arm has limited mobility due to weakness secondary to cva. Has a 20 gauge saline lock to right forearm. Site is free from redness or drainage, with tegaderm dressing intact. (if your patient has an infusing iv, make sure you record the fluid and rate in your assessment). Uses urinal, has occasional episodes of incontinence. Urine clear yellow. No skin breakdown noted. Ted hose on bilaterally. Homan's sign negative bilaterally. Feet cool, dry, intact, with thick toenails bilaterally. Side rails up x 3, bed in low position. Call bell within easy reach of right hand. Instructed to call for any needs or to request assistance before attempting to get up. Verbalized understanding. Side rails up x 3. Will continue to monitor closely.............................. S. Johnson, SN, *****

VickyRN, MSN, DNP, RN · Jun 30, 2007

Another example of narrative charting, this time with multiple sequential entries:

Example: pt with tracheostomy on the rehab unit.

0700 – Assumed care of pt after reporting on the primary nurse. Received pt in bed, resting quietly with eyes closed. Easily aroused to alert and fully oriented state with voice. Client indicates by shaking head that presently he has no needs and no pain or distress. Respirations even, unlabored via tracheostomy. Pt is receiving humidified oxygen @ 28%, 6 liters, via trach collar. Sao2 97% on continuous pulse oximetry. Trach site is midline and patent, and trach collar is secure to site. Breath sounds are course, with diminished air flow @ bases anteriorly and posteriorly. Suction, ambu bag, and oxygen set-up are at bedside. Pt hob is mid fowler’s. Instructed to call for any needs; pt verbalized understanding. Call bell within reach, sr up x 3, bed low position with wheels locked. Will continue to monitor closely.

0730 – fsbs 280 per glucometer # 4. 6 units novolog insulin administered subcutaneously under supervision of instructor @ left upper outer arm. Pt tolerated well. Sao2 98%.

0820 – eating 1800 calorie ada breakfast (no fluid restrictions) without any signs or symptoms of aspiration. Feeding self; indicates he needs no assistance. Scheduled medications administered without difficulty. Sao2 96%.

0900 – pt given percocet 5/325 mg oral dose per request, in anticipation of scheduled occupational and physical therapy. Sao2 97%.

0915 – ot in room with patient. Pt indicates that he is tolerating therapy well. Sao2 98%.

1000 – pt denies pain. Rates pain 0/10. Physical therapy at bedside. Pt taken off unit via wheelchair with portable o2.

1100 – back to room; indicates he tolerated physical therapy well. Denies pain. Hooked back up to humidified oxygen 28% 6 liters, sao2 98-99%. Tracheostomy care performed under supervision of instructor. Inner cannula changed out. Site without erythema or discharge. Skin intact. Patient tolerated well. Pt denies need for suctioning at present time. Only small amount of thick yellow mucous noted, which patient adequately coughs up.

1130 – fsbs 205 per glucometer # 4. 4 units novolog insulin administered subcutaneously @ right upper outer arm, under supervision of instructor. Pt tolerated well. Denies any needs. Sao2 98%.

1200 – sitting up in chair. Eating lunch in no acute distress. No changes noted from earlier assessment. Trach remains midline, patent, and intact. Humidified oxygen 28% 6 liters via trach collar, continuous pulse oximetry. Sao2 96%. Call bell within reach. Reported off to primary nurse.

(This is just an example. Be sure any abbreviations you use are approved by the facility and your instructor! Otherwise, write out all abbreviations such as "pt" and "fsbs"! :))

caliotter3 · Jul 1, 2007

Due to the National Patient Safety Guidelines, my last employer changed their policy to exclude abbreviations in narrative charting. It is probably best not to develop the habit of using abbreviations.

Daytonite, BSN, RN · Jul 2, 2007

I just have to post this because it kind of relates to this thread. I was in the hospital for surgery this week and in between the pain and the grogginess, I had a good time schmoozing with the various RNs assigned to me. I want you all to know how important good documentation is. The hospital nurses worked 12-hour shifts 7a to 7p and 7p to 7a. Around 10am yesterday I walked out into the hallway and found my 7p to 7a RN sitting at an isolated desk toward the far end of the surgical unit--CHARTING! This was no new graduate as we had several conversations. She felt, as I did when I was actively working in the acute hospital, that it was more important to stay and finish charting and make it as thorough as possible.

Now, she may have a time management problem, but I cannot say. However, her purpose was certainly clear. She wanted the work she had done during her shift to be correctly and completely documented because you never know who is going to be looking at what you've written. I never apologized or complained about the times I stayed over to finish my charting. And, if my bosses gave me grief about it, I clocked out and finished my charting on my own time because I felt it was for my professional and personal benefit. There's no way I was ever going to have to be on a witness stand and be made to look like a boob by an attorney. If you've never seen it, watch the movie, The Verdict, and how the attorneys treat the doctors and the nurse who changes the outcome of the malpractice trial the story is about. While a lot of it is done for dramatic purposes, the real deal can be a lot harsher and colder. At one of the legal seminars I attended we were shown a 15-minute video of a nurse being questioned by an attorney. It was awful as the attorney pointed out all the things the nurse didn't do or chart what she had done. The lawyer made the nurse look incompetent. And all he did was act polite and ask nice questions that were designed to bring out the flaws in her documentation that he wanted the jury to hear. On top of that he had a huge blow up of her actual page of nurses notes for the jury to see. They were sloppy and there were several places where she had scratched out the information she had written (wrong way to correct a document).

Diary/Dairy, RN · Jul 11, 2007

The pace that I am working at now does not have narrative charting for this unit EXCEPT if the patient is a admission or discharge....I think it is a bit strange... There are places to note if problems arise, but there are no shift notes as such - anybody else run into this???