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How to write narrative charts

How to write narrative charts

by Isabel
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Narrative charts are a way to record patient data. This allows nurses and doctors to quickly consult patients and plan for future treatment. Nursing students who are successful will be able to use both the SOAIP and DAIR methods of narrative charting. Each letter in the acronym DAIR represents a step in the information-gathering and treatment procedures: Data, Assessment, Intervention and Response. Each letter in SOAIP represents a type or data: Subjective, Assessment, Assess, Intervene, Propose, and Observation. To be proficient at narrative charting, you must practice making observations and drawing reasonable conclusions. Then, formulate the best plan of actions based on these conclusions. Nurse narrative note.

DAIR Charting
Step 1
You can gather empirical evidence using your five senses as well as established facts. Keep track of the facts you believe to be true under the “D” category.

Step 2
You can use the “A” section of the form to assess the data and draw conclusions using your knowledge and experience as a nurse.

Step 3
Assist the patient if necessary and note the actions you took in the “I” section of the narrative charting.

Step 4
Under the heading “R”, record the patient’s reaction to your intervention.

SOAIP Charting
Step 1
Ask the patient for details about the incident that led to the injury or symptoms of the illness. Record these under the “S” category to gather subjective information.

Step 2
You will gather empirical evidence using your five senses and other established facts. Take notes of the patient’s appearance and sound during the subjective step. Also, note any additional observations and keep them under the heading “O” for objective information.

Step 3
Analyse the data in “A” and draw conclusions based upon your knowledge and experience as a nurse.

Step 4
Assist the patient if necessary and note the actions taken in the “I” section of the narrative charting.

Step 5
You may suggest additional measures that could be needed in the future to provide relief. For example, you might consider administering another dose after the prescribed time. Your recommendations should be recorded in the “P” category.

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.

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