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General concepts 1. Besides the initial entry and assessment, narrative notes include all patient care activities such as diet, hygiene, ambulation, elimination, visits from health care professionals (Dr, PT, etc) or family, tests, specific problems, how addressed and how resolved. All entry are signed and dated. Every timed entry must have a legal signature 1st initial, last name and legal status. !". #urse, B$#%& The last entry on a page must have a le al si nature. Plan the last entry on a page so it has a logical statement and signature. 'ou may have to have a partial blan( line to do so and may have to continue the same timed entry on the ne)t page. *ll blan( lines have lines drawn to end of line or to signature Each pa e of narrative notes is a legal document must be dated!and si ned" Sa#ety chec$s% "ost hospital protocols re+uire you to document that your patient has been chec(ed for safety at the initial entry, + , hours and the last entry. This must also be included in your narrative notes. -hen referring to another nurse in your documentation, include her 1st initial, last name and legal title. !Pt c.o shortness of breath, P. %mith, /# notified&.

2. 3. 4. 5.

Initial entry% -hen you perform your initial assessment, you will ta(e vital signs, briefly assess the patient0s status in all systems, and chec( that all ordered modalities, e+uipment, and treatments are in place and properly functioning. 'our initial entry will include level of consciousness1 ability to follow directions1 general status of the s(in, respiratory system, cardiac system, and bowel sounds1 the status of systems related to current diagnosis or surgery1 any untoward findings1 the status 23s, drainage tubes, dressings, and any special e+uipment1 and then end with a safety chec(.

07:30 Alert, awake, orientated to person place and time. Follows commands. Skin warm and dry. Respirations unlabored @1 . Apical !ulse " #, re$ular. %owel Sounds absent. &and $rasps e'ual. (#@ )* +ia nasal cannula. ,- ./010#1S in2usin$ @100 to R 2orearm +ia pump. Site clean and dry wit3 no swellin$ or redness. Abdominal dressin$ dry and intact. Foley drainin$ clear amber urine. 4ompression boots in place. 56.S in place. %ed in low position, call bell in reac3, siderails . 7. 1urse, %41S
&ocumentin diet. The amount of fluid in m4s is recorded in the 256 sheet. 2n the narrative note document the type of diet, percentage consumed, and any pertinent information

0 :00 5ook 1008 o2 low sodium, so2t diet. &ad di22iculty swallowin$ c3opped meat.97. 1urse, %41S
&ocumentation o# complete physical assessment. $omplete your assessment before 7 a.m. and before giving any medications or treatments. 2t may not all be actually completed at the same time, but document it in one paragraph ma$in sure that any a'normal or critical #indin s are documented and reported immediately .

*s( the patient specifically when he had last B". 2n addition to stating !no complaints of constipation diarrhea or flatus&, describe your patient0s specific status.

0 30 Awake, alert, oriented to person, place : time. Skin warm and dry. 5ur$or recoil brisk. Face symmetrical. !6RR*A. 6(7 intact. Follow spoken commands. 7ucous membranes pink : moist. Swallows wit3out di22iculty. 1eck supple, trac3ea midline, carotids e'ual, no cer+ical nodes palpated. ;-. <=> @ )/ 8. Respirations e+en and unlabored, rate 1?. %reat3 sounds clear bilaterally : A:!. Apical !ulse"7#, re$ular. Abdomen so2t, non=tender, bowel sounds present in all ) 'uadrants. 1o complaints o2 constipation, diarr3ea, 2latus. States last %7 yesterday e+enin$. @rine amber, no complaints o2 burnin$. 7A6 wit3out di22iculty. !erip3eral pulses #A. &omanBs si$n <=>. 4apillary re2ill brisk. %ed in low position, call li$3t wit3in reac3. SR.999999999999999999999999997. 1urse, %41S

&ocumentation o# hy iene care "ost institutions have a chec(9off list of nursing interventions for hygiene, such as bac( care, pedicure, :oley care, mouth care. ;owever, they should be included in a narrative note. *lso indicate how much of the care the patient did independently and any pertinent observations.

0C:30 4omplete bat3 care $i+en wit3 mout3 care, peri=care, Foley care, back care.997. 1urse, %41S
&ocumentin am'ulation% Describe gait, strength, amount of assistance needed, how tolerated.

0C:30 ((% to c3air wit3 t3e assistance o2 two sta22 members. Dait steady, but slow. Ambulated in 3allway / minutes. 40( E2eelin$ tired.F, assisted back to bed999999999999999999999999999999997. 1urse, %41S
&ocumentin a pro'lem such as pain %tate the problem, what was done to solve it, and record result.

10:1/ States Es3arp painF points to **G o2 abdomen, on a scale o2 1=10. States E$ets a little better w3en lyin$ on le2t side.F Respirations #0. .emerol 7/ m$ ,7 R +entral $luteal site by 7. Real1urse, R1. Side rails , bed in low position, call li$3t in reac3. 7. 1urse, %41S
and the result (or evaluation of whether your intervention was successful)

11:00 States pain 3 on scale o2 1=10. Hatc3in$ 5-.9999999999999999997. 1urse, %41S

&ocumentin a physician visit( a test( therapy( treatment( specimen%

10:30 .r. ;ones in to see patient.9999999999999999999999999999999997. 1urse, %41S 10:)0 5o I=ray +ia w0c 2or c3est I=ray999999999999999999999999999997. 1urse, %41S 11:)/. Sputum Specimen to lab.99999999999999999999999999999999997. 1urse, %41S 1#:00 Abdominal dressin$ c3an$e. J midline, +ertical abdominal incision well= approIimated. Staples intact. 1o redness, swellin$ or draina$e noted. .ry sterile dressin$ applied.9999999997. 1urse, %41S
)INAL ENTR*% 3erify status of your patient and include safety chec(

1#:1/ States pain Ealmost $oneF, now a 1 on 1=10 scale. &usband +isitin$. Hatc3in$ 5-. Side rail call bell in reac3, bed in low position.999999999999999999999999999999999997. 1urse, %41S