Nursing Narrative Note Template
Attend to your patient's needs and enhance note-taking procedures within clinical environments without compromise.
Fact Checked by Ericka Pingol.
What is a Nursing Narrative Note Template?
Nursing narrative notes are commonly used within hospitals for nurses to provide concise information concerning a patient's condition. They're an immensely useful note-taking format that facilitates better treatment outcomes and healthcare solutions. Through this, you can observe and record all critical information concerning the patient care received and produce rich insights highlighting the various nuances and subtleties of a patient's health.
Unlike progress notes, nurses' notes are in paragraph form, allowing for a more detailed account of a patient's health status. Healthcare professionals can receive a full record that captures all details, which may be needed in ambiguous or complicated cases where more information is needed.
Nursing Narrative Note Template
Nursing Narrative Note Template Example
What should be included in a nursing narrative note?
A well-structured nursing documentation is crucial for ensuring the continuity of the patient's care, promoting patient safety, and meeting legal and professional standards. Here are the key elements that should be included in a nursing narrative note:
Subjective data
The subjective data section captures the patient's perspective, including their chief complaint or what the patient reports as their reason for visit, current symptoms described by the patient, relevant quotes in their own words, and a pain assessment using a standardized scale.
Objective data
Objective findings form the backbone of clinical assessment in a nursing narrative note. This section should include vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation), physical examination findings, the patient's medical history, relevant lab and diagnostic test results, medication administration details, and any treatments or procedures performed.
Assessment
The assessment section of a nursing narrative note synthesizes the subjective and objective data to provide a clear picture of the patient's status. It should include an overall evaluation of the patient's condition, interpretation of clinical findings, noted changes since the last assessment, and the patient's response to interventions or treatments.
Plan
The plan section outlines the next steps in patient care, including specific nursing interventions, patient education, referrals or consultations, pending tests or procedures, and any follow-up requirements.
The nursing narrative note can also be used alongside our Progress Notes for Nursing Template for informing clinical decision-making and medical record-keeping.
Nursing narrative note templates are commonly used within hospitals for nurses to provide concise information concerning a patient’s condition. They’re a note-taking format that is immensely useful in facilitating higher treatment outcomes and healthcare solutions. Through , you can observe and record all critical information concerning the care received, as well as produce rich insights that highlight the various nuances and subtleties of a patient’s health.
Unlike progress notes, nursing narrative note templates are in paragraph form to allow for a more detailed account of a patient’s health status. Healthcare professionals can receive a full record that captures all details, which may be needed in ambiguous or complicated cases where more information is needed. Integrating narrative nursing note templates can see more efficient care and better development of assessments that directly address both prominent and underlying healthcare issues. Create an accurate storyline of your patient’s healthcare journey, and elevate the level of care in your workplace.
How to use this Nursing Narrative Note Template
To use the nursing narrative note effectively, it's helpful to consider the following steps.
Step 1: Access the PDF template
To access the nursing narrative note, download the PDF template. It should open automatically within your PDF reader software. Then, you can fill in and customize the template to match your nursing process. You can also refer to the nursing notes examples PDF in the preview to serve as a reference as you write this note.
Step 2: Fill in the important credentials
To prevent the documents from being mixed up and to ensure they are authorized, fill out your patient's full name, ID, gender, date of birth, and appointment date. Signing the document at the bottom completes this process and ensures you are responsible for its contents.
Step 3: Complete the body sections
The next step is to fill in all the body sections of the template. Check over your information to make sure it is accurate and concise. You can refer to the information in the "What should be included in a nursing narrative note?" section on this page as a guide to help you structure your notes.
Step 4: Securely store your notes
Once complete, you must store the note securely on a HIPAA-compliant platform. This is highly important, as you're dealing with PHI, which must be protected and at minimal risk from external data breach attempts.
Benefits of nursing narrative notes
In addition to their usefulness, nursing narrative notes offer many benefits for healthcare providers, such as:
Save time
Having narrative note templates means you don't have to work on their structure. They're ready-made, with all the important details listed for you. Of course, feel free to adapt to your needs, but this shouldn't take any additional time. Healthcare is busy enough as it is, so save time where you can to do what you do best: attend to patients and their health conditions.
Improve clinical outcomes
Nursing narrative notes include all essential information, meaning you can spend more time noting rich insights and critical details about the patient's condition. As a result, you can elevate the quality of clinical outcomes and work towards higher recovery rates, which is always a big plus!
Greater communication
Narrative notes allow for more detailed descriptions of health conditions and concerns, which means you have greater freedom when painting a representative picture of a patient's health. You can communicate their thoughts, feelings, and professional judgments. As a bonus, enhancing attentiveness to health conditions can inevitably increase client satisfaction and foster greater professional relationships.
Make informed decisions
Healthcare involves making the right choice for your patients. This can sometimes feel incredibly daunting, especially in cases where the answer isn't always obvious. Narrative nursing notes can help you have more confidence in your decisions, with more insight and evidence guiding you.
Legal and insurance protection
If your patient becomes involved in a legal case, your notes must serve as sufficient evidence to prove professional judgment and sound opinion. You can highlight your train of thought and identify how you reached certain conclusions. This can increase the accuracy of insurance claims and receive faster reimbursements. Narrative notes outline all resources used within patient treatment and assessment, which makes for easy evidence records.
Integrating narrative nursing note templates can result in more efficient care and better assessment development that addresses vital signs and underlying healthcare issues.
Commonly asked questions
There's no right way to write a good nursing note for a patient's progress. However, you should keep some tips in mind. Firstly, keep them concise. Because you're writing a narrative note, this doesn't mean that you can write an entire essay about a patient. Your note may be more comprehensive than a SOAP, but it must be succinct for clarity. Avoiding abbreviations to minimize confusion and double-checking that all medical terms are correctly applied and spelled are also recommended. It can be easy to get things wrong when writing notes amid a busy session, so always take the time to review!
Yes, your patient will likely view these nurse notes, so it's important always to use objective data and avoid biased or judgmental comments. All statements should be medically based and supported with relevant evidence. This is standard practice and should be done regardless of whether your patient views your notes.
Nursing charting is similar to nursing narrative notes in that medical assessment and intervention details are listed. However, nursing charting is more specific and is broken down into specific sections. It is considered less insightful and is typically used in large organizations that see many patients or during busy periods. Narrative notes are a good way to assess more broadly, with several details included for patients with complex health issues.
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