How to Write a Narrative Nursing Note

What Is a Nursing Narrative Note?

The narrative is probably the most common type of nursing note or documentation or at least the most universal across all states and hospitals. While flowsheets and other formalized charts may differ greatly and take some time to get used to, narrative notes do not have a rigid structure and follow the same general guidelines regardless of the department and qualification. 

Narrative notes are short stories depicting an incident of patient care, starting with an inciting incident, such as a change in condition, leading up to a climax - an intervention based on objective and subjective data, and concluding with a resolution of the issue and improving the patient’s condition. Notes are usually short, no more than a couple of paragraphs long, and they complement the formalized patient documentation. A collection of narrative notes reads like a story of the patient’s hospital stay. 

The Purpose of Writing a Nursing Narrative Note

As an example of narrative documentation in nursing, narrative notes help establish smooth communication and understanding among medical professionals working with the same patients and ensure the best possible care. Fellow nurses and doctors can easily assess the patient’s condition and learn about the interventions provided even when you are off-shift and beyond the hospital walls.

The narrative note’s less pleasant but equally crucial purpose is to keep a clear record and protect your reputation and license. Remember that every note added to the patient’s chart is a legal document that can be used as evidence to assess the validity of your actions by your superiors, administration, and litigators. Keeping an objective, detailed, and honest record of everything you do to help a patient can save you and the hospital a lot of trouble.  

The Benefits of Nursing Narrative Notes

Developing and mastering the skill of writing narrative notes is crucial for nursing students and new registered nurses alike. While seemingly tedious and cumbersome, narrative note-taking comes with plenty of advantages for you, your patients, and your career:

1. Unlike flowsheets and other formalized documentation, narrative notes provide unprecedented freedom to keep track of the patient’s condition, interventions, and treatment outcomes. You can develop a personal style of narrative note-taking to make it more efficient and fast.
2. Narrative notes help create a full picture of the hospital stay. When it comes to writing a narrative note nursing staff can include information that doesn’t fit formalized paperwork, thus adding new layers and value to the patient’s chart.
3. Narrative notes keep track of changes, not routine. The regular information goes into the flowsheet and other forms. At the same time, notes focus the doctors’ and nurses’ attention on occurring shifts in the patient’s condition that require attention, resulting in a better understanding of the condition, better care quality, and positive outcomes.
4. Building your narrative note-taking skills helps you grow as a nurse and advance your career. Keeping paperwork in order is an easy way to get noticed by the administration and get on the fast track to a management position.

The Key Elements of a Nursing Narrative Note

While there are no standards or rulebooks, most nurses follow the same guidelines for narrating in their notes. There are eight core points you should include in every note. Check out a sample nurses note narrative or two at the end of this post for more details. You’ll notice, each one contains most if not all of the following details:

1. Date and time. Both are vital when coupled with other paperwork and notes, as they create a cohesive timeline of the patient’s condition, treatment, and outcome.
2. Patient’s name. Identifying the patient is critical in hospital wards to avoid confusion and mixups, so make sure every note has a clear name and other identifying information.
3. Cause of concern. Explain what prompted you to write the note: the patient’s call, strange monitor readings, or visual signs of distress.
4. Objective assessment. Detail the results of your examination based on the cause of distress, including readings, lab results, and the signs you notice throughout your exam.
5. Subjective assessment. Note the patient’s description of the problem, their symptoms or emotional state, as well as the assessment by their visitors, if any are present. 
6. Intervention details. Describe the actions taken to address the issue: treatments conducted or medication administered.
7. Intervention outcome. Wait for the intervention results and document the positive changes if they occur based on a new round of objective and subjective assessment.
8. Follow-up details. In case your intervention does not result in positive changes, note your next actions: who you call or page, their instructions or actions, and the outcomes achieved.
9. Signature. Sign the note with your name and title to make it easily identifiable for your colleagues.

While the list may seem lengthy, actual narrative notes are usually shorter than this overview.

How to Write a Nursing Narrative Note

1. Note What’s Different

Start your note with what’s concerning you or your patient. It can be unusual skin color or behavior, labored breathing, depressed emotional state, or an actual complaint from the patient. You can also notice something concerning on the monitors during your rounds, like low oxygen saturation or elevated blood pressure. Whatever is out of the norm should make it to your note.  

2. List Objective Assessment Results

Detail all assessment techniques you use and their results in the nursing narrative note. List blood pressure, heart rate, oxygen saturation, lung noises, lab results, etc. Any piece of hard evidence you can get your hands on that has something to do with the occurring problem should be in your note. 

3. Supplement Subjective Data

Ask your patient about the symptoms, the frequency of occurrence, the pain levels, recent changes in their condition, etc. You don’t have to conduct a complete head-to-toe assessment, but any useful information you can get about the new development will provide valuable data for your note and further treatment plans. 

4. Detail the Intervention Administered

Provide detailed information about your actions to address the patient’s issues. These can range from setting up an IV to administering prescribed medication or requesting a consultation with the doctor. List medication names and dosages, along with the prescribed treatment plan for easy assessment. 

5. Note the Treatment Outcome

Evaluate the results of your intervention and add them to your note. Include the updated results of an objective and subjective assessment. Quantitative parameters should return to their normal levels, and the pain should decrease to a manageable intensity, etc. In case the intervention does not result in a positive outcome, devise a follow-up plan, including a call for a doctor. 

6. List All Professionals You Engage

If you page a doctor for a consultation and receive instructions on how to proceed, explain this in your note. The same is true for engaging an MD for a face-to-face visit with your patient. Everyone responsible for helping your patient with the current issue should be listed in your note. If possible, collect their signatures on your note as evidence of their presence and decision-making.  

7. Double-check Your Note

Before adding the note to the patient’s chart, give it a once-over to check you’ve included all pertinent information. Ensure you’ve included the date and time, the patient’s name, and your signature. Look over the numbers and medication names to ensure they are correct and legible. Remember that everything you log should reflect your decisions and actions. Inaccurate data in the narrative note can cause you problems, even if you did everything right.  

Tips For Writing An Excellent Nursing Narrative Note

Study Hospital Guidelines

Narrative notes are subject to in-hospital guidelines and rules, not federal standards, so you need to learn the local way of writing them whenever you get a new job. Study the rulebook and ask around to learn the best practices and adapt your way of note-taking to what you learn. For example, some hospitals incorporate nurses’ notes into the EMR, while others don’t.  

Use the SOAPIER Approach

If you’re still working on your note-taking style, remember the problem-based approach coded in SOAPIER: subjective data - objective data - assessment - plan - implementation - evaluation - revision. It’s an easy way to remember and visualize what needs to go in your note and the right order of detailing your actions.

Make It Legible

If you’re stuck with handwritten notes, make sure someone besides you can read what you write. After all, notes are meant for sharing information, so you want to make your writing as clear as possible without any risk of misinterpretation. Remember, a nurse narrative note is a legal document, so it can be used against you in litigation, and it’s in your best interest to make it easy to understand.

Avoid Ambiguity

Your note should be as easy to understand as it is to read. You can rely on commonly used acronyms, but avoid them if there’s any risk of misinterpretation. It may take you longer to write the full name of the condition or lab test, but it will help your colleagues make sense of your notes and protect your patients from mistakes in treatment. 

Write Notes as You Go

Do not leave your narrative notes until the end of your shift, as you risk mixing up or forgetting details. Instead, get into the habit of writing up your notes as soon as you are sure the patient responds positively to your intervention.  

Remain Objective

Your emotional responses to the patient or their family should stay out of your note-taking. Keep your writing professional and on-point. And avoid making assumptions based on verbal evidence alone. Instead, rely on objective data and use the patient’s remarks to supplement it.

Update Your Notes

Unless your patient is discharged the moment you finish the note, you may need to add new information to their charts. While you don’t generally add new information to the note, you can create a new one that references previous interventions but includes a new date, time, and assessment details. 

Prioritize Information

As a nurse, you should be able to tell which of the patient’s complaints are critical and which are based on emotions rather than facts. So when writing a narrative note, prioritize core details, lead with them, and add other details as needed to explain your assessment or treatment choice.  

Be Succinct but Descriptive

Narrative notes are short stories, not novels of the medical profession. You need to convey all pertinent information while keeping unnecessary details to a minimum. It takes time to hone the skill of tight, descriptive writing, so keep practicing to find the right balance and develop a personal note-taking style.

Common Mistakes When Writing Narrative Notes

We’ve gone over things you should do to make your writing actionable and helpful. Now let’s go over the common errors new and experienced nurses make when dealing with narrative notes. The list below is prioritized from the most to the least offending, so if you notice something you do high on the list, work on it first before correcting other mistakes.

1. You never use narrative notes. Unless it’s your hospital policy, narrative notes are a useful day-to-day tool for providing your patients with the best care possible.
2. You list symptoms without addressing them. This turns a narrative note into a written version of the patient’s complaints and is mostly useless for your colleagues, so remember to add assessment, intervention, and evaluation details as well.
3. Your note ends in a negative intervention outcome. If your treatment does not help, seek assistance from fellow nurses or doctors and detail their recommendations and your future plan of action in the narrative note.
4. You make baseless assumptions. Note-taking is designed to document actions, not your speculations about the causes of the patient’s problems, lifestyle, character, etc. Only add data based on objective evidence or the patient’s subjective assessment.
5. You submit your notes before reviewing the intervention results. Do not presume the treatment is successful until you get hard evidence, such as monitor data or the patient’s claims.
6. Your descriptions are vague. You need to squeeze as much detail as possible into a short note, but that’s not an excuse to make it imprecise. Use facts and numbers instead of generalizations.
7. You let emotions get the better of you. Even if the patient gets on your last nerve, and is loud and angry, do not let it cloud your judgment or narrative note-taking. Describing the patient as ‘crazy’ isn’t helpful because it’s not a proper diagnosis that can be supported by objective evidence.
8. You include the patient’s personal information in your notes. Unless this data is the cause for the current health issues, the patient’s recent divorce, breakup, or spat with a sibling has no place in your notes.

Examples of Nursing Narrative Notes

08/26/2021 1000

Patient was admitted to ED at 0900 with a 2-day history of RLQ abdominal pain and onset of nausea at 0600, and intensification of RLQ pain. Patient reports taking 800 mg of OTC ibuprofen at home without significant pain relief. Administered 4 mg morphine and 4 mg ondansetron via IV. Pain reduced from 8/10 to 4/10, nausea is reported to be under control. Patient s/p CT of abdomen results show acute appendicitis per radiology. Patient admitted to ward with 18 g IV to R AC, received 1 L NS in ED. Appendectomy planned for 08/27/2021 at 0900. 

03/18/2021 1610

The patient reported shortness of breath during afternoon rounds. Patient’s speech pattern included short, 3-word phrases with heavy breaths between them. Oxygen saturation is 87% on RA, on auscultation, crackles are noted, zero use of accessory muscles. 10L oxymask administered, HOB increased to 45%, oxygen saturation increased to 92%, oxymask replaced with a 2L nasal cannula. Patient reports easier breathing. Will wean off oxygen and keep oxygen saturation under observation. 

11/29/2021

Patient reports dry cough continued over the last ten days that turned into productive cough within the last two days. The expectoration is reported to be white. The patient was prescribed Mucinex on 11/25/2021 and reports medium improvement, but the cough remains prominent and disturbs the sleep cycle. Advised the patient to use pillows to create an elevated sleeping position for easier breathing during sleep and increase the moisture level inside the bedroom to promote productive cough and the continued use of Mucinex. The patient reports improved breathing and reduced coughing upon implementation. 

01/15/2022 0900

The patient reports getting dizzy upon getting up. Supine blood pressure 130/70 drops to 100/60 when the patient changes position. A significant drop in blood pressure leads to dizziness and can cause fall-related injury. Raised all side rails to prevent falls, placed a call button within easy reach, and instructed to call for assistance when getting out of bed. Doctor Smith paged at 0910; page returned at 0913 with a planned assessment by the doctor at 1000. Will continue observation and treatment upon doctor’s assessment. 

05/09/2022 1225

Patient responding to unseen stimuli, unresponsive to communication attempts. Responded to visual assessment by becoming loud and argumentative with the nursing staff. Doctor paged for consultation, revised medication plan based on apparent behavior. PRN medication administered at 1145 on the doctor’s instruction. The patient continues to respond to unseen stimuli and declines the lunch tray. Will continue observation and schedule a doctor’s assessment for further treatment revision.