Narrative Note HELP :)

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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

555 Posts

Specializes in Legal, Ortho, Rehab.

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

27 Posts

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 :)

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