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

Book Synopsis: 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
• 44 Complete Examples Inside!
• Assumption of care
• Provider at bedside
• End of shift handoff
• New admission
• Admit from emergency department
• Admit from PACU
• Admit from clinic
• Inventory of belongings on admission
• General surgery pre-op
• General surgery post-op
• Status post bariatric surgery
• Patient transport off ward
• Ambulation
• Venipuncture
• Foley placement
• NG insertion
• Status post TKA
• Status post THA
• Status post TSA
• Circulation in surgical extremity
• Physical therapy consult
• Occupational therapy consult
• Gynecological diagnosis
• Urological diagnosis
• Gastrointestinal diagnosis
• High risk for falls
• IV infiltration
• Allergic reaction
• Blood product reaction
• Fall without injury
• Fall with injury
• Follow up after a fall
• Leaving AMA
• Non-compliance with provider’s orders on diet restriction
• Refusing medication
• New onset arrhythmia, asymptomatic
• New onset arrhythmia, symptomatic
• Equipment malfunction
• Narcan for overdose
• Rapid response
• Code blue
• Discharge
• Transfer to outside facility
• Template for ease of writing narrative notes

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