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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.
Colloquially known as “charting,” nursing documentation provides a record of nursing care provided to a patient, family, or community. Charting and, more specifically, nursing notes, allow nurses to demonstrate that the care they provided was ethical, safe, and informed by relevant nursing knowledge.
Nursing progress notes are a narrative summary of the care provided by the nurse during a patient encounter. Nursing progress charts include nursing progress notes and other vital information relevant to the patient’s status from admission until discharge.
Sample Documentation of Unexpected Findings. Patient is alert and oriented to person, place, and time. Speech is clear; affect and facial expressions are appropriate to situation. Patient cooperative with exam and exhibits pleasant and calm behavior.
Sample Documentation of Expected Findings. Patient denies any new onset of symptoms of headaches, dizziness, visual disturbances, numbness, tingling, or weakness. Patient is alert and oriented to person, place, and time. Dress is appropriate, well-groomed, and proper hygiene.
A nursing note is a detailed record that captures the comprehensive care provided by nurses. It includes the nurse’s observations, assessments, nursing diagnoses, care plans, interventions, and evaluations of patient outcomes (ADPIE). Nurse notes are a key part of patient care documentation.
Is nurse charting the bane of your existence? See different examples of nursing notes and discover tips to improve your documentation skills.
Patient documentation is permanent record, and, well, you probably became a nurse for the hands-on interaction. That’s OK! Here’s a refresher on what and how to chart as a nurse, as well as tips for avoiding some of the most common documentation mistakes.
Documentation and reporting provide valuable learning materials for nursing students and healthcare professionals, offering real-life case studies and examples to enhance understanding and skill development.
Layout 1. ANA’s. Principles for Nursing Documentation. Guidance for Registered Nurses. Summary. Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice.