Narrative Note HELP :)

[squishy11]

Hi all--

Just looking for a little help... I made it through my first semester with flying colors, however now I am in Med Surg. I felt I was doind well and getting the concepts, but then.... our first test.. sigh... I did pass with a 76 (passing is a C in our program) , and 50% of the students were below a 66. So I am not sure how I feel about this...

Anyhow... I have to write a narrative note (which is my worst enemy at this point.. still) on my patient who has pneumonia -- a few people have handed in notes already, and were reamed for having 'too much info' on them. And I think that is because we are also in Health Assessment.. and that instructor wants about a page of assesments on each system.... so.. my quesiton is this -- how do I write a narrative note for an elderly woman who was admitted for pneumonia... ?

Thanks you

[nyteshade, BSN]

Start with the basics or general survey.

Age, sex, CC, dx, VS, ABCs, Ins (IV, etc), Outs (foley, drains, etc)

Move on into a focused pulmonary assessment. Include relevant subjective/objective data. Any interventions you've done. How the patient tolerated any of your interventions.

This is just a guide.

[squishy11]

thanks for the advice. I am guessing a lot of my classmates maybe put too much into it. So I have it written, and we shall see how it goes. It was shorter then my classmates, but is right to the point. I started at the head, and went down to the toes..

Kinda of nice tho, my last instructor just wanted SOAP notes, and those, I can do in my sleep now... so I am hoping narratives will become my friend the more I do them :)