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Discussion

Narrative Charting

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?

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    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.

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

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

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    • Expert

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

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