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5 Nursing Narrative Note Examples + How to Write
Written By: Darby Faubion BSN, RN
One of the most important lessons nursing students learn is the importance of documentation. Whether you are a nursing student or a seasoned nurse, knowing how to create accurate nurses' notes is vital. Narrative nurses' notes are one of the most popular forms of nursing documentation. Perhaps you are wondering how to write a nursing narrative note? In this article, I will share 5 nursing narrative note examples + how to write them and discuss the importance of accurate charting.
What Is A Nursing Narrative Note?
A nursing narrative note is a type of nursing documentation used to provide clear, detailed information about the patient. A narrative note is written in paragraph form and tells a story, if you will, about the patient, the care he is receiving, response to treatment, and any interventions or education provided.
What Is The Purpose Of Writing A Nursing Narrative Note?
Nurses spend more one-on-one time with patients than physicians, which means we are in a better position to observe subtle changes in the patient's status, behavior, and responses to treatment. The nursing narrative note is a crucial component of patient care. The purpose of the narrative nursing note is to provide accurate information from nursing assessments including the care provided, patient conditions, and other relevant information to help the clinical team provide high-quality, efficient care.
What Is The Difference Between A Nursing Narrative Note And A Nursing Progress Note?
Taber's medical dictionary defines a Nursing Progress Note as an "ongoing record of a patient's illness and treatment." Physicians, nurses, therapists, and consultants record notes concerning a patient's progress or lack of progress between the time of the previous documentation to the most recent one. While nursing narrative notes and nursing progress notes may have the same information on them, narrative nursing notes are created in paragraph form. On the other hand, progress notes may be in paragraph form or on progress template forms, depending on the facility's preference.
3 Advantages Of Nursing Narrative Notes
There are pros and cons to using each type of nursing note or documentation. Healthcare facilities use different types of notes based upon preference and need. The following are a few advantages of using narrative nursing notes.
1. A nursing narrative note allows nurses to give a detailed account of their patient's status, including changes in body systems and responses to treatments.
2. Narrative nurses' notes are easily combined with other types of documentation, such as graphs and flow sheets.
3. Nursing narrative notes offer more flexibility in documenting. While there are guidelines nurses should follow to chart effectively, nurses develop their own style of writing and communicating that is unique to them.
3 Disadvantages Of Nursing Narrative Notes
While there are advantages to using narrative nursing notes, there are also disadvantages. The following are a few cons related to the nursing narrative note approach.
1. It can be time-consuming to read through several narrative notes, which can delay treatments or responses to patient needs.
2. Nursing narrative notes are typically used to create a story or timeline of what is happening with a patient. While this approach is helpful when it comes to pinpointing when changes occurred, this type of note is not necessarily focused on patient outcomes.
3. The nursing narrative note can become lengthy and often repetitious. When using this style of documentation, it is important for nurses to be thorough but mindful of repeating information unnecessarily.
What Elements Should Be Included In A Nursing Narrative Note?
Narrative charting is a great tool to use in patient care. What the nurse documents impacts nursing care plans and physician decisions. Therefore, it is essential to try to create an excellent nursing narrative note. When creating a narrative nurses' note, make sure the following elements are included.
• Date and Time:
All narrative nursing notes should begin with a date and time entry. This important element of the note helps keep the storyline of the patient's chart in order and makes it easier to look back and find pertinent information related to a specific event.
• The Patient's Name:
Some facilities require the patient's name to be listed in every entry. Others may have a place at the top or bottom of the page where the patient's name and room number must be entered. It is each nurse's responsibility to make sure identifying information is on the patient's chart to prevent documenting on the wrong patient.
• Subjective Data:
Subjective data refers to information the patient can provide to the nurse. This data includes symptoms the patient is experiencing, level of pain, thoughts, or concerns.
• Objective Data:
This type of data is the opposite of subjective data in that objective data is information the nurse collects or observes about the patient. Objective data includes the patient's appearance, observable signs or symptoms (grimacing with pain, holding on to the wall when walking because of dizziness), vital signs, and laboratory results.
• Assessment:
Depending on the reason for the assessment, this part of the nursing narrative note may include a head-to-toe assessment or a targeted assessment. For example, nurses caring for a post-operative patient may write a post-operative narrative note to describe how the patient is doing in recovery, post-op vital signs, and signs or symptoms of complications.
• Interventions:
All nursing interventions should be documented. For example, if you assist with turning and repositioning, provide education, or administer medication, it should be documented.
• Evaluation:
All nursing interventions should be followed up by an evaluation to determine the patient's response. The amount of content included in the evaluation will depend on the patient's status. If you are evaluating the effectiveness of pain medication, the evaluation part of your note may only need to say, "Pt reports pain medication effective in relieving back pain."
What Elements Should Not Be Included In A Nursing Narrative Note?
When creating a nursing narrative note, omitting specific things is as important as including pertinent information. This does not mean you should omit information specific to the patient's condition, care, or response to treatments. The following are a few things that should not be included in a narrative nurses' note.
1. Symptoms Without Intervention:
Any time you document symptoms (objective or subjective), your documentation should include an intervention and follow-up. Do not chart symptoms or patient complaints without documentation about how the situation was handled.
2. Speculations:
You may feel like you know your patient better than anyone else. Granted, you may know him very well, but it is not our job as nurses to speculate about what a patient is thinking or feeling. Instead, pay attention to what the patient says and does and document what you see and hear.
3. Non-Descriptive or Non-Precise Terminology:
The nursing narrative note should create an image or story in the reader's mind. Therefore, precise and descriptive terminology is necessary. For example, instead of charting "bed soaked with urine," the nurse should write "Pt. Incontinent of bladder; adult brief and bed pad changed due to wetness from incontinence; peri-care provided; no s/sx of compromised skin integrity."
4. Premature Charting:
Nurses should never document care before care is complete. This is important because even the most well-planned days can have unexpected things happen that delay or prevent treatment.
5. Personal Information About the Patient's Family or Loved Ones:
If your patient has a friend or loved one visit, it is acceptable to document it. For instance, you may write, "Pt. Alert, spouse and children at the bedside, no complaints." However, it is never appropriate to put personal information such as whether they were rude to you or the patient or seemed intoxicated, etc.
HOW TO WRITE A NURSING NARRATIVE NOTE?
(The following is a step-by-step process to write a perfect nursing narrative note.)
Nurses use several methods to create nurses' notes. One of the most popular formats nurses use in narrative charting is known as SOAPI, which stands for Subjective, Objective, Assessment, Plan, and Interventions.
1. Stay on point and be specific
Narrative nursing notes are great options for documenting in-depth details about every aspect of the patient's status and response to treatment options.
2. State the facts
The nursing narrative note is your opportunity to describe what you hear, see, feel, and do. While you want to be thorough, don't embellish. Keep it simple by stating the facts.
3. Note presentation
The nursing narrative note should identify the patient's primary complaint or problem first then any secondary issues.
4. Note objective data
Information such as vital signs or things you can visualize.
5. Record subjective data
After you note objective information, add subjective data you gather from the patient.
6. Make notes regarding your assessment
Assessment notes should begin with objective assessment such as finger stick blood sugar results. The patient's loved one may have reported concern about the patient's altered mental status, which is subjective assessment information.
7. Record any medication you administer or treatment you perform
Document how the patient handled any procedure.
8. Did you have to include interdisciplinary team members?
If you report the patient's status or other information to another team member, supervisor, or physician, document who you reported to. If that person has not yet responded, be sure to document "awaiting response."
9. Don't forget to sign each entry of your note with your name and credentials
A nursing narrative note that does not have the nurse's signature is not complete.
WHAT ARE SOME EXCELLENT EXAMPLES OF NURSING NARRATIVE NOTES?
(Below are 5 excellent nursing narrative note examples.)
Example #1: Head-to-Toe Admission Assessment Narrative Note for Patient admitted with recent Cerebrovascular Accident (CVA)
02/17/22, 1845. 79 y/o white female admitted to Med-Surg bed 4, DX recent Rt CVA. Vital Signs upon admission: BP 150/84, Pulse 78, Resp 20, Temp. 98.8 (oral). Patient is alert and oriented X3, responds appropriately to verbal commands and stimuli. Speech is clear with no signs of slurring. Patient's spouse reports some episodes of dysphagia. Soft mechanical diet ordered r/t increased risk for injury r/t dysphagia; typically feeds self with little to no assistance. PERRLA, 3 mm bilaterally. Unequal grips noted with obvious right-sided deficiency. Notable weakness in right leg and foot. Patient is at risk for falls due to limited mobility; side rails up X 4. Negative Homan's sign; at risk for DVT due to immobility, TEDS applied bilaterally, active ROM right leg, passive ROM left leg q4 hrs. Pedal pulses present, palpable, and strong bilaterally. Capillary refill <2 seconds bilateral lower extremities. Lungs clear to auscultation bilaterally. At risk for pneumostatic pneumonia due to limited mobility; patient will TCDB q hr., up in chair TID with 2 person assist. Bowel sounds active and present x4. Abdomen is soft, nontender to palpation. Patient reports last BM 2/16/22, soft, brown, well-formed, denies history of constipation or bowel incontinence. Patient also reports infrequent episodes of urinary incontinence occurring primarily in the early morning or during the night. Perineal area assessed and found to be clear and intact, no signs of redness or irritation noted. --------------------------------------------------------------------------------D. Parker, RN, BSN
Example #2: Assessment of Nursing Home Resident
2/14/22, 0730. Resident K.B. is an 80 yr. old black male, alert and oriented to person and place, but not oriented to date or time. Oriented patient to date and time verbally and wrote the date on a notepad by his chair. Calm, pleasant affect; denies complaints of pain, discomfort, or any new concerns. Skin is warm and dry to touch; no pallor or cyanosis noted; turgor fair. Bilateral upper extremities have some purpura, but the skin is intact. No edema noted in bilateral lower extremities. Peripheral pulses present x2 in upper and lower extremities. Patient is on O2 @ 2L per NC with no signs of skin breakdown near the nose or ears from the NC; lungs sound clear bilaterally, chest symmetrical. Approx. 300 cc clear, amber urine in urinal, urinal emptied and cleaned; Abdomen is slightly firm and tender to touch. Bowel sounds present in upper quadrants, but hypoactive in lower. Resident reports last BM "may have been a few days ago." Per CNA flowchart, no BM noted since 02/10/22. VS stable: BP 130/72, P 70, R16, T 98.6. Notified Ms. Head, Assistant Director of Nursing of abdominal tenderness and no BM, administered Fleet's enema x1 per standing order.--------------------------------------------------------------------------------------------------------M. Boles, RN@0830. CNA assisted resident to BSC; resident passed a large amount of hard, dark brown stool. Instructed resident about the importance of having regular bowel movements and measures to help promote healthy bowel habits, including increasing water and fiber in the diet and avoiding too much junk food. Resident voiced understanding and jokingly stated, "I guess I have to tell my grandkids to take it easy on bringing the sweets." Denies any complaints, pain, or discomfort at this time. -----------------M. Boles, RN
Example #3: Nursing Narrative Note Example for Patient Recently Admitted and Found on Hospital Floor
1/29/22, 1625. 69 y/o white female admitted this morning for observation following a fall at home. Pt. Found on floor in her room at beginning of this shift after attempting to go to restroom unassisted. Pt states she "wasn't sure if that light thing worked," referring to the call light. Assisted back to bed and assessed for injuries, none apparent. VS stable: BP 120/72, P 68, R 18, T 98.1. Alert and oriented x3. Instructed patient on the use of call light and demonstrated it works. Pt. Verbalizes understanding of the importance of calling for assistance before getting out of bed to prevent falls or injuries. CNA assisted pt .to restroom while nurse present and assisted back to bed. Side rails up x2, bed in the lowest position, call light within reach.---------------------------------------------------------------------------------------------------M. Gray, RN
Example #4: Patient with Complaints of Left Knee Pain
02/12/22, 0930. 28 y/o African American female presents with complaints of left knee pain x3 days. Pt. Reports she was jogging three days ago (02/09/22) and felt a slight "twinge" in her knee but was not overly concerned at the time. She reports pain worsened within the last 24 hours despite the alternating warm and cold compresses and taking ibuprofen for the discomfort. Pt. rates scale 5/10 on the pain scale presently. VS stable: BP 118/78, P 76, R 20, T 98.6. Redness, bruising, and minimal swelling were noted around the left knee. Pt. denies falling. PERRLA. Bilateral hand grips equal. Denies dizziness or headache. Skin W&D to touch, turgor good. Capillary refill <3 seconds. Resp. even, nonlabored; lungs CTAB, chest symmetrical. Abd. Soft, non-tender, BS active x4, last BM today. Denies any urinary complaints. Radial pulses present x2 upper extremities, pedal pulses present x2 lower extremities. Pulses, strong and regular. Report given to Dr. Bullows. --------------------------------------------------------------------------------------------J. Lin, RN
Example #5: Patient Complaint of Nausea, PRN Medication Administered
01/06/22, 1345. Pt. c/o nausea denies vomiting but states he feels like he may be sick, requests medication to ease stomach discomfort. VS: BP 100/64, P 70, R 18, T 98.4. O2 Sat 98% on room air. Abdomen is soft, BS active x4 quads. Pt reports some abdominal tenderness when palpated. Continent of bowel; reports last BM 01/05/22, normal consistency, and denies any history of diarrhea or constipation. Promethazine 25 mg. (one) given po, as per prn order for N&V. Continent of bladder with 18 Fr. indwelling foley catheter with leg band attached to right thigh, catheter is patent to gravity with approx. 200 cc pale yellow urine in foley bag. Skin is warm and dry to touch, turgor fair. Peripheral pulses present x2 upper and lower extremities with good capillary refill. Skin is warm and dry to touch, turgor fair, no edema noted. No skin tears or lacerations noted, no integumentary compromise noted on visual assessment. PERRLA. Lungs CTAB. Mucous membranes pink and moist. ----------------------------M. Sikes, RN@1430. Reassessed pt. for c/o nausea and vomiting. Pt. reports nausea has subsided since taking medication at 1345. Denies vomiting or other complaints currently. Bed in low position, SR up x2, call light within reach. ----------------------------------------------------------------------------------------------------------M. Sikes, RN
BONUS! 6 Expert Tips For Writing An Excellent Nursing Narrative Note
If you are going to document about patient care, there is no reason you should not write an excellent nursing narrative note. The following are some tips to help you create great narrative nurse's notes.
1. Document nursing actions immediately.
The longer you wait between nursing interventions, assessments, and documentation, the greater the chance of omitting important details.
2. Keep Documentation Descriptive.
The nursing narrative note should clearly state everything that is observed by or reported to the nurse. Descriptive documentation reduces the risk of information being misinterpreted.
3. Be objective.
When creating narrative nurses' notes, it is important to keep an objective view. Although you may report subjective information as well, the things you observe (objective data) are crucial for decision making.
4. Add new information anytime it is necessary.
Unfortunately, writing a narrative note and signing off on it does not mean you will not see a change in your patient's status or that the doctor will not issue a new order. Anytime something new occurs, create a new entry with the date and time and any pertinent information.
5. Convey Enough Information to Get Your Point Across.
At times it may be necessary to write longer narrative nursing notes. The idea is to give enough information to make the message clear and cover all important aspects of the patient's status, needs, treatment, and responses without writing a novel full of frivolous or unnecessary details.
6. Make sure your handwriting is legible.
If your facility still uses paper notes, this tip is especially important. Always remember, the patient's chart can be used as a legal document. If anything about your patient's care were ever called into question, you want to be sure your entries are clearly legible to information is not misunderstood.
My Final Thoughts
One of the most important things you can do is learn how to create exceptional nursing narrative notes. That is why we chose to address the question of how to write a nursing narrative note? By using the 5 nursing narrative note examples + how to write them featured in this article, you can create high-quality, professional nurses' notes. Remember, it is always better to document more than enough than not enough.
FREQUENTLY ASKED QUESTIONS ANSWERED BY OUR EXPERT
1. Who Can Write a Nursing Narrative Note?
Any licensed nurse can write a narrative nursing note. Additionally, nursing students may write narrative notes if their school's clinical contract allows it. Some clinical sites require nursing instructors or a staff nurse to review the student nurse's notes and sign beside them.
2. When To Write a Nursing Narrative Note?
It is best to write nursing narrative notes as soon as possible after performing an assessment, administering a medication or treatment, or when any other pertinent event occurs related to the patient's care. Failure to write notes in a timely manner increases the chance of forgetting important information or forgetting to document altogether.
3. Can I Use Abbreviations in a Nursing Narrative Note?
You may use abbreviations for medical terms in narrative nursing notes. However, it is best to use whole words whenever possible instead of abbreviations. If you have questions or are unsure about a proper medical abbreviation, always err on the side of caution and use whole words.
4. What Tense Do You Write a Nursing Narrative Note?
The tense a narrative nurses' note should be written in varies. For example, if you are documenting at a patient's bedside, you can chart in what you see in the present tense. On the other hand, if you must document an incident that occurred, you would document it in the past tense. A general rule of thumb is to document as much as possible at the patient's bedside or outside their hospital room. However, there may be times when documentation cannot be done until you are at a nurse's station. It is always best to verify your facility's protocol.
5. Are Nursing Narrative Notes Handwritten or Printed?
Narrative nursing notes may be printed or handwritten. The most important thing is to make sure they are legible. If you print more clearly than you write in cursive or vice versa, that is the method you should use.
6. How To Sign Off a Nursing Narrative Note?
All nurses' notes should be ended with the nurse's signature and title. For example: Darby Parker, RN, BSN. Some facilities require nurses to include the date and time at either the beginning, ending, or both of each entry. Be sure to verify your facility's protocol for nursing documentation.
7. What Happens If I Forget to Write a Narrative Note in the Time It Should Have Been Written?
Failure to complete nurse's notes promptly and accurately can have negative consequences for nurses, the organizations who employ them, and patients. If you forget to write a narrative nursing note and do not remember until you have left work, call your employer immediately and ask to speak to the nursing supervisor. Report the oversight and any information about the patients you cared for that day. Your narrative note should be written as soon as possible. Create a nurse's note which includes events and other information with the date they occurred in your note. Be sure to document on the note that it is a late entry.
For example, "2/14/22@0800 (Late entry for care provided on 2/13/22) On 2/13/22, Ms. Riley called the nurse's station with complaints of nausea and vomiting. On assessment, the patient had no fever or signs of dehydration. Administered Phenergan 25 mg, one po, as per PRN order. Upon reassessment, Ms. Riley reports decreased sensation of nausea and no additional occurrence of diarrhea."
8. Should I Write About a Patient Crying in My Nursing Narrative Note?
Nursing narrative notes should be written in a way that they create a picture in the mind of the reader. If your patient is anxious, crying, or frustrated, these indicate emotional distress, which can occur in response to a medication, upsetting news, or physical illness. Therefore, it is important to write about your patient crying.
9. How to Note Pulses on a Nursing Narrative Note?
Vital sign assessments, including pulses, should be assessed and documented carefully. When you write about a patient's pulse rate, the following information should always be included: the amount of time you assessed the pulse, the pulse rate, pulse quality, and which pulse site you assessed. For example: "Right radial pulse rate 74 X1 minute. Pulse rate is strong and steady. Patient denies any complaints."
10. How to Describe Lab Results in a Nursing Narrative Note?
Clinical lab results are used to monitor and diagnose health issues and screen for possible illnesses and diseases. Results should be documented carefully, as up to 80% of treatment decisions are based on those results. When documenting lab results in a narrative nursing note, the name of the test and date and time the test was performed, the method by which the specimen was obtained, when results were received, and to whom results were reported should be included.
For example, "On 2/15/22, patient was instructed on proper procedure to obtain a midstream clean catch urine specimen for analysis. Patient obtained the specimen and was submitted to medical center lab for testing. Results received on 2/17/22 were as follows: Color-dark yellow, Clarity- turbid, pH 7.0, Leukocyte esterase- positive, Nitrite- positive, WBCs 20. All other ranges are within normal limits. Results faxed to Dr. Smith, primary care provider, and reported to charge nurse, Ms. Smith."
11. Can A Nursing Student Write a Nursing Narrative Note?
Nursing students can write narrative nursing notes. Students learn the steps to complete nursing narrative notes and what information to include in the classroom where they practice documentation. Some facilities require a nursing instructor or staff nurse to sign behind a student.
12. What Are the Common Mistakes Nurses Make When Writing Narrative Notes?
Some of the most common mistakes nurses make when preparing narrative nursing notes include failing to record a patient's response to a PRN medication, failure to document when a medication such as an antibiotic is completed, or a medication is discontinued, not recording the date and time the note is written and delaying documentation.
Darby Faubion BSN, RN
Darby Faubion is a nurse and Allied Health educator with over twenty years of experience. She has assisted in developing curriculum for nursing programs and has instructed students at both community college and university levels. Because of her love of nursing education, Darby became a test-taking strategist and NCLEX prep coach and assists nursing graduates across the United States who are preparing to take the National Council Licensure Examination (NCLEX).
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Source: https://www.nursingprocess.org/nursing-narrative-note-examples.html