Documentation is a critical component of patient care, and narrative nurse's notes provide all the unique details that can't be covered in a one-size-fits-all form.
Those details allow clinicians to see a more complete picture of the condition of their patient and sometimes directly lead to a complex or unusual diagnosis that may have otherwise been missed.
10 TIPS FOR WRITING EFFECTIVE NARRATIVE NURSE'S NOTES
Because nurses spend so much time with their patients and are in a better position to observe subtle symptoms and changes in behavior, it's important that they work to develop the skills needed to produce effective nurse notes.
Below are 10 tips for improving the quality of your narrative nurse's notes.
1. Be Concise
Nurse notes are meant to document the extra details that can't be showcased in standard data sets, but it's important to keep to pertinent information.
“The key to writing effective narrative nursing notes is to be concise in the facts while telling the story of an event," says Catherine Burger, RN and media specialist for RegisteredNursing.org.
She goes on to point out that narrative nurse's notes are often used to summarize information not found in flowsheets, document unusual events or lay out a shift summary that can be easily digested by the medical team.
Keeping nurse notes to the point eliminates time that would be wasted reading details unrelated to the patient's condition.
2. Note Actions Once They are Completed
A healthcare professional must be able to trust that any actions listed in the narrative nurse's notes have already been completed.
With the fast-pace environment of healthcare facilities and the high probability of unexpected change, including actions in nurse notes you haven't actually done yet opens you to the possibility of false documentation.
For the same reason, make sure to note any actions that have been taken. "If it is not documented, it was not done," says Judith R. Sands, RN and author of Home Hospice Navigation: The Caregiver’s Guide.
3. When Using Abbreviations, Follow Policy
Because nurse notes are shared among medical professionals, only facility-approved abbreviations should be used.
Your notes will confuse other providers if you deviate, leaving your patients open to medical mistakes.
4. Follow SOAIP Format
To cover your bases, nurse notes should follow the SOAIP format learned in nursing school, says Burger.
- Subjective information: symptoms reported by the patient
- Objective information: observation of the patient's condition
- Assessment: information from the initial examination
- Intervention: what steps were taken in response
- Plan: notes about follow-up care and doctor notification
"Although all of this data could be recorded in a flowsheet," she admits, "the narrative allows the story of the event to be conveyed."
5. Never Leave White Space
Large blank spaces between notes can leave doctors wondering if something was missed.
Was the space left intentionally, or did the nurse forget to include the information that should have been there?
Nothing should ever be left blank on a chart.
6. Limit Use of Narrative Nurse's Notes to Avoid Discrepancies
Narrative nurse's notes have a specific purpose and should only be used to summarize events or make note of something unusual. Using them too often or writing lengthy narratives can result in contradictory information in the patient file.
"If the nurse is adding a long narrative note after all of the data sets or flowsheets are reordered, there is an opportunity for data discrepancy, and [it] can put the organization at risk," cautions Burger.
"For example, if the nurse completes all the data sets as 'within normal limits' for a neuro assessment, but then adds a narrative of an untoward event involving a change in level of consciousness, that can be an obvious discrepancy to a lawyer or regulatory agency."
7. Document Immediately
It's important to get narrative nurse's notes down as quickly as possible. As more time passes between a medical event and subsequent documentation, the chance of omitting an important detail or embellishing information increases.
This is especially critical should medical complications arise that warrant a liability claim or fraud investigation.
"Given the era of EMR (electronic medical records), it is more critical than ever for documentation to be timely," states Sands. "Late entries cast a shadow of doubt no matter how innocent the situation may be."
8. Add New Information When Necessary
If you've completed your narrative nurse's notes but experience a change in your patient's condition, go ahead and document it below the notes you've already written.
Be sure to include the time (using the 24-hour format) for each documentation to distinguish different events.
As long as you are limiting yourself to factual records of medical events and aren't repeating information, it's important to document any changes.
9. Follow "Late Entry" Protocol
If an entry is missed, it may be added later if facility protocol is followed.
The note must include a late entry designation, and nurses should add it as soon as possible.
Entries become less credible as more time passes and create legal liabilities for the facility and medical professionals.
10. Keep Documentation Objective and Descriptive
Above anything else, it's important to keep narrative nurse's notes objective. While it may be appropriate to include treatment or diagnostic suggestions, all information must be presented in a neutral way with no emotional components.
Keeping notes descriptive is also necessary to allow other healthcare professionals the opportunity to reach evidential medical conclusions.
"Documentation needs to be objective and clearly describe what is observed and stated," mentions Sands. "Describing observations is critical, rather than labeling with a generic term that could be misinterpreted."