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

by Lena Empyema

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.When to use a narrative noteComponents of an effective narrative noteHow to refer to yourself and othersHow to phrase your notesThe best practice for referring to timeCommon phrases to avoidAbout double documentationHIPAA specific to narrative notesAbbreviationsTips to streamline your narrative note writing processThe notes to write for every patient on every shift44 specific examples for situations commonly encountered in medical/surgical or lower acuity units44 Complete Examples Inside!Assumption of careProvider at bedsideEnd of shift handoffNew admissionAdmit from emergency departmentAdmit from PACUAdmit from clinicInventory of belongings on admissionGeneral surgery pre-o,General surgery post opStatus post bariatric surgeryPatient transport off wardAmbulationVenipunctureFoley placementNG insertionStatus post TKAStatus post THAStatus post TSACirculation in surgical extremityPhysical therapy consultOccupational therapy consultGynecological diagnosisUrological diagnosisGastrointestinal diagnosisHigh risk for fallsIV infiltrationAllergic reactionBlood product reactionFall without injuryFall with injuryFollow up after a fallLeaving AMANon-compliance with provider’s orders on diet restrictionRefusing medicationNew onset arrhythmia, asymptomaticNew onset arrhythmia, symptomatic,Equipment malfunctionNarcan for overdoseRapid responseCode blueDischargeTransfer to outside facilityTemplate for ease of writing narrative notes

88 pages, Kindle Edition

Published January 5, 2020

Reviews

[Sonia Neblett-burnett · Rating 5 out of 5]

Documentation

This was a great book fir me. I have bern an LVN for 30 yrs and wish I would have had this when I started nursing. I just graduated from RN school and will be using it.

[Chimkin · Rating 4 out of 5]

Nurse of 8 years still learned something from this book! Reinforced some other personal ideas I had about charting and gave me a few extra vertebrae for my next rebuttals if management wants to disagree with how I'm charting. Definitely a must for nursing students and new nurses!

[Tiara Lighty · Rating 5 out of 5]

very good

This was a very good guide to proper note writing for a variety of situations. Perfect for the novice nurse.

[Shasta Hamlin · Rating 5 out of 5]

Very helpful information if you need some help with documentation.

[Noelle Mahasin · Rating 5 out of 5]

Good Read

Good book to help with all of your nursing charting. Lots of helpful tips and examples. Really great for new nurses.