COMPLETE A RESIDENTS NURSING NARRATIVE NOTES

How To:

COMPLETE A RESIDENTS NURSING NARRATIVE NOTES.

Click on Resident Care –Current Resident.

Click on choose a resident (small arrow down on right hand side).

Choose a resident by name.

Once you have chosen your resident, their name and photo will appear on the screen.

Once you have chosen your resident, Click on Nursing Narrative Notes.

The residents name and photo will appear to ensure you are in the correct notes.

Click on ‘Help’ to reveal a PDF document that provides guidance to nurses on writing narrative notes.

PDF document that provides guidance to nurses on writing narrative notes.

Previous Narrative Note entries will appear in Current Notes.

Type new narrative note entries in New Narrative Notes.

Remember to check the hca’s Routine Daily Care records before you write your narrative notes so as to know what care the resident received during the shift –just click on View RDC Record.

The Routine Daily Care Records (RDC) will provide information on what care the resident received during the shift and may assist you with what to include in your narrative notes.

You can also look at previous days  Routine Daily Care Records (RDC) by choosing the dates you want to view.

You can also just look at one particular domain’s records e.g., breathing or nutrition by using the ‘filter’ button.

To return to narrative notes –just click Close.

You can also check the residents most recent vital signs prior to writing you narrative notes, if needed by clicking on ‘View latest Vitals’.

To return to narrative notes –just click Close.

You can view older nursing narrative notes by clicking on ‘Historical Notes’.

Choose the dates (time period) you want to view and click on ‘View’.

To return to current narrative notes –just click ‘Close’.

When an incident or event happens, you are required to record it in the Daily Event Log (as well as writing about it in the nursing narrative notes). This is to allow for collecting of data / figures on the number of events such as the number of falls or skin tears or infections in the centre.

The ‘Daily Events Log’ can be found on the right hand side of the screen.

Daily Event Recording

You will need to record resident events in the Daily Event Log e.g. a fall, skin tear, urinary tract infection, etc, on the day that the event occurs. Please do not record the same event/incident twice e.g. where a resident presents with an infection such as a urinary tract infection, it should only be recorded once on the first day of the infection and not on any additional days that the infection continues.

Just click on the appropriate event button once. You can click on more than one event, if you want e.g. Fall and Skin Tear.

To return to current narrative notes –just click ‘Close’.

You should also review the ‘Status of Resident’ each time you write your narrative note by clicking on ‘Update’ and editing the tick boxes as required.

To exit the residents Nursing Narrative Notes –just click ‘Close’.

Things to Remember when completing the Nursing Narrative Notes.

Before starting your narrative notes, don’t forget to review the status of resident.

Don’t forget to check the Hca’s daily care records (RDC) before you write your narrative notes! Also, don’t forget any Daily Event recordings!