Sample narrative note PDF

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Mrs. Noss- Clinical Patient Narrative Note (Sample) One note required on each patient for your shift. IF there is a change in pt status, another note must be written!

ALL NARRATIVE NOTES WILL BE WRITTEN ON PAPER AND SUBMITTED TO ME FOR APPROVAL BEFORE PLACING ON THE ELECTRONIC CHART. All submissions will added to Electronic chart before 11 am. Any subsequent submissions will be added as needed with my prior approval.

Pt awake, alert, and oriented X3. Skin warm and dry. Color fleshtone. Not c/o ___________ (chest pain, dyspnea, dizziness, nausea, vomiting, etc.) (Based upon patients diagnosis (es). IV of ________________________ (ex. NSS, D5W. D5NSS with 20 meq KCL, etc) r/A (running and absorbing) well at ___________/hour into ___(site)______________. Dressings-_____________________________________________________________________. ASSESSMENT- (SYSTEM FOCUSED- BASED UPON PT’S PRIMARY AND SECONDARY DIAGNOSES) Lungs clear upon auscultation, Abdomen soft + BS X4 quadrants. Include here any tubes- foley cath, penrose, n/g, chest tube, urology tubes, etc… Telemetry monitor on and audible. Call bell in reach. Bed pad alarm on . Bed in lowest position. Will continue to monitor. See flow sheet for further assessments....