Author: Lena Empyema

Publication date : January 6, 2020

Language : English

Print length : 89 pages

ISBN-10 : 165656548X

ISBN-13 : 978-1656565488

Item Weight : 5.6 ounces

Dimensions : 6 x 0.21 x 9 inches

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-o,

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