Nursing Narrative Note Examples to Save Your License: Charting and Documentation Suggestions for RNs & LPNs Who Have to Describe the Indescribable in a Medical Record - Tapa blanda

Sinopsis

Within electronic medical records, drop-down boxes and fill-in-the-blanks replace some free-texted notes. To supplement the flowsheets in EMRs, nurse narrative notes tell the rest of the story.

In this book, I bring life to an otherwise mundane topic, provide clarity for nurses about what to say in narrative notes and how to say it, and empower nurses to feel confident that their charting tells the whole story in enough detail to defend their actions.

I'm an RN-MSN myself, not an attorney, so I understand nurse documentation from a relatable perspective. The information in this book is the product of more than a decade working in health care and hours of research over the course of more than two years, condensed into an easy-to-read format that can be skimmed for nurses short on time, or read more in-depth for nurses who want to truly master writing narrative notes.

CONTENT:

• When to use a narrative note
• Components of an effective narrative note
• How to refer to yourself and others
• How to phrase your notes
• The best practice for referring to time
• Common phrases to avoid
• About double documentation
• HIPAA specific to narrative notes
• Abbreviations
• Tips to streamline your narrative note writing process
• The notes to write for every patient on every shift
• 44 specific examples for situations commonly encountered in medical/surgical or lower acuity units

1. Assumption of care
2. Provider at bedside
3. End of shift handoff
4. New admission
5. Admit from emergency department
6. Admit from PACU
7. Admit from clinic
8. Inventory of belongings on admission
9. General surgery pre-o,
10. General surgery post op
11. Status post bariatric surgery
12. Patient transport off ward
13. Ambulation
14. Venipuncture
15. Foley placement
16. NG insertion
17. Status post TKA
18. Status post THA
19. Status post TSA
20. Circulation in surgical extremity
21. Physical therapy consult
22. Occupational therapy consult
23. Gynecological diagnosis
24. Urological diagnosis
25. Gastrointestinal diagnosis
26. High risk for falls
27. IV infiltration
28. Allergic reaction
29. Blood product reaction
30. Fall without injury
31. Fall with injury
32. Follow up after a fall
33. Leaving AMA
34. Non-compliance with provider’s orders on diet restriction
35. Refusing medication
36. New onset arrhythmia, asymptomatic
37. New onset arrhythmia, symptomatic,
38. Equipment malfunction
39. Narcan for overdose
40. Rapid response
41. Code blue
42. Discharge
43. Transfer to outside facility
44. Template for ease of writing narrative notes

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