Nursing-Narrative-Note-Examples-to-Save-Your-License-Charting-and-Documentation-Suggestions-for-RNs--LPNs-Who-Have-to-Describe-the-Indescribable-in-a-Medical-Record

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Nursing Narrative Note Examples to Save Your License:
Charting and Documentation Suggestions for RNs &LPNs
Who Have to Describe the Indescribable in a Medical Record
Sinopsis :
Within electronic medical records, drop-down boxes and fill-inthe-blanks
replace some free-texted notes. To supplement the
flowsheets in EMRs, nurse narrative notes tell the rest of the
story.In this book, I bring life to an otherwise mundane topic,
provide clarity for nurses about what to say in narrative notes
and how to say it, and empower nurses to feel confident that
their charting tells the whole story in enough detail to defend
their actions.I'm an RN-MSN myself, not an attorney, so I
understand nurse documentation from a relatable perspective.

The information in this book is the product of more than a
decade working in health care and hours of research over the
course of more than two years, condensed into an easy-toread
format that can be skimmed for nurses short on time, or
read more in-depth for nurses who want to truly master writing
narrative notes.CONTENT:When to use a narrative
noteComponents of an effective narrative noteHow to refer to
yourself and othersHow to phrase your notesThe best practice
for referring to timeCommon phrases to avoidAbout double
documentationHIPAA specific to narrative
notesAbbreviationsTips to streamline your narrative note
writing processThe notes to write for every patient on every
shift44 specific examples for situations commonly encountered
in medical/surgical or lower acuity units u 44 Complete
Examples Inside! /u Assumption of careProvider at
bedsideEnd of shift handoffNew admissionAdmit from
emergency departmentAdmit from PACUAdmit from
clinicInventory of belongings on admissionGeneral surgery
pre-o,General surgery post opStatus post bariatric
surgeryPatient transport off wardAmbulationVenipunctureFoley
placementNG insertionStatus post TKAStatus post THAStatus
post TSACirculation in surgical extremityPhysical therapy
consultOccupational therapy consultGynecological
diagnosisUrological diagnosisGastrointestinal diagnosisHigh
risk for fallsIV infiltrationAllergic reactionBlood product
reactionFall without injuryFall with injuryFollow up after a
fallLeaving AMANon-compliance with provider&#8217orders
on diet restrictionRefusing medicationNew onset arrhythmia,
asymptomaticNew onset arrhythmia, symptomatic,Equipment
malfunctionNarcan for overdoseRapid responseCode
blueDischargeTransfer to outside facilityTemplate for ease of
writing narrative notes