Narrative Charting

[grannypatches]

I am a LPN nursing student. Today at school all of us were told that if we get 2 you's on our nurses notes and care plans that despite our grades we are out of the program. I freaked out. This is second semester and its hard. We are cramming 16 weeks into ten. I am maintaining good grades but my nurses notes are the worse. Can anyone direct me to good websites showing good examples of how narrative nursing notes should be. I have searched to no avail. I am sending for the book "charting made easy" but it will not arrive for a while. I was so upset when I came home I fell across the bed exhausted and nearly in tears. I have worked so hard in school and 2 you's can end it all. I already have 1 you. Any good advice for a stressed out struggling LPN student?

[Daytonite, BSN, RN]

diarygirl512 said:

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???

(Please note that you have posted onto a thread in a nursing student forum). I would check your hospital policy on charting. Every hospital form is supposed to have a guideline as to how it is to be used. It will either be the Nursing Department or the Medical Records Department that will have this information. I would also look for a hospital form for nursing narrative notes. If there are any special clinical nurse practitioners in your facility, they are charting somewhere. There should always be some kind of option for a nurse to add some kind of narrative note to the chart. If no one can give you an answer, ask someone in the medical records department. If there is a place where nurses can chart a narrative note, they will know where it is or if there is a special form because they are the keepers of the medical records. There were instances in some places that I worked where we charted on the physician's progress notes, but I would check before doing something like that.

[misdetermined, LPN]

aaa rn said:

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.

I know this is an old post but I just have to say...OMG...THANK YOU FOR THIS!!! I am a new LPN grad and I have been working for about 2 weeks now and struggling when it comes to narrative notes. This was extremely helpful and will use this as my template from now on.

[Candwloc, LVN, RN]

All this stuff is really helpful. I am just now learning how to chart going into my 3rd and final semester of VN school.

[Tracy425]

Ugggh...I feel your pain!!! Please let me know if the book is helpful!

[Esme12, ASN, BSN, RN]

They may not answer you.......This is an old thread from 2007 but contains valuable information about charting.