Narrative Nurse’s Note
For this discussion, develop an example of a narrative nurse's note you would write for a patient encounter.
Provide a full assessment or a portion of charting for a morning, afternoon, or night shift.
Develop the post as if it were the actual chart entries in a narrative format as opposed to computer entires.
The minimum number of entries is 7 and the maximum is 10.
Include background information at the start of your post. For example allergy status, DNR status, medical, surgical, or social history. Medication compliance. Etc.
It is acceptable to document your notes by using elements from different common patient scenarios or making up a patient to document on.
Example
Background: Provide relevant information that would not normally be included within a documented note entry.
Gender, age, appearance
chief complaint; LOS to date
Home meds; allergies
Format for each entry: Month/day/year in this format [xx/xx/xxxx] military time; Entry. Your Name and credentials.
