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A nursing narrative note is a component of a patient's chart or intake form that provides clear and detailed information about the patient and her symptoms. Narrative notes should be clear and succinct, but also offer sufficient information for doctors and nurses to analyze the patient's condition and make appropriate medical recommendations.
Keep it Succinct
Don't incorporate opinion or try to make your writing beautiful. Narrative notes need to be succinct and easy for busy medical professionals to quickly read. Focus only on the specific issue you're charting. For example, a patient with a history of diabetes who also presents a skin problem does not demand detailed charting of his diabetic history. Instead, you'll only need to chart information that is or could be relevant to the patient's skin problems.
Make it Comprehensible
Narrative notes should be short, but if you must convey a significant amount of information, break your narrative into paragraphs for easy scanning. Use only abbreviations that are widely used and accepted at your hospital or clinic. If abbreviations for two similar conditions or treatments look very similar, avoid using them altogether and instead write out the full names of the conditions or treatments. If you write your notes by hand, keep your handwriting clear so that your reader doesn't inadvertently give an incorrect medication or dosage based on bad handwriting.
Note Patient Presentation
Your narrative note should clearly identify the presenting problem, as well as any secondary problems you notice or about which the patient complains. Note objective measures of patient health, such as blood pressure and heart rate. Next, note any subjective measures, such as skin color and whether the patient appears anxious.
Your narrative note should outline any and all assessments you administered, starting with objective assessments such as blood panels. If you utilized subjective assessments, such as accounts from family and friends of the patient's state of mind, note these as well. Conclude with the probable diagnosis and the findings of any assessment measures. If more tests are indicated or the patient may be suffering from a disorder that has not yet been diagnosed, note this as well.
Note Medication and Treatment
After you or another medical professional have completed the assessment, list any and all medications your patient has been given, as well as the dosage and mechanism of delivery. If a doctor prescribes medication, list this medication and the dosage as well as any other medications the patient regularly takes.