Nursing Narrative Note Examples

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#1

 Reason(s) for Home Health Recertification

• Un-resolving Pain Episodes
• Sleep Disturbances
• Un-resolving GERD

Comprehensive home visit SN assessment and evaluation of all of patient’s body systems, needed for recertification to home health services for episode period 09/03/2011 – 10/31/2011. Patient has a past medical history Schizophrenia, Alzheimer’s, OA, and GERD. Patient has abnormal balance and gait while walking. Patient and caregiver were educated on safety and fall precautions e.g. wear slip resistant footwear, keep walkways clear of debris, keep house well lit, and transfer positions slowly. Patient is able to complete his ADL’s safely with no to minimal assistance. Medications were reconciled and med profile was updated. Patient’s medications are administered by group home staff. SN will need to monitor medication effectiveness. Plan of care reviewed and agreed upon by patient. Patient today reports diminishing response to pain medication, exacerbation of GERD, and increased frequency of constipation in recent times. Patient was instructed upon measures to avoid episodes of GERD as follows: Eat smaller meals. Large meals fill the stomach and put pressure on the LES, making reflux and GERD more likely.

#2

Reason(s) for Home Health Recertification

• Chronic Bronchitis
• Poorly Managed Blood Sugars

Patient reports cough for the last 10 days. It gradually started with dry cough and gradually turned productive in the last 2 – 3 days. Patient reports expectoration to be white in color. Patient was prescribed Mucinex on 03/16/2010. Patient reports some improvement, but cough is still prominent. Blood sugars over the certification period have been very poorly managed. Most of the readings were fasting readings over the certification period. The fasting readings varied between 150 – 266. All the readings were of the SN visits. More than half the readings over the certification period were in the 200s. Patient has no log of her every day blood sugar readings. Caregiver was instructed to maintain a log of the same. Reportedly, the patient has poor compliance with the dietary limitations. No falls reported. No hospitalizations happened over the certification period. Patient had one episode of UTI in the last cert period.

Example 3

Reason(s) for Home Health Recertification

• Exacerbation of Gouty Arthritis
• Noncompliance with Allopurinol

Patient reports that he has an exacerbation of gouty arthritis, secondary to the drop in temperatures. Also, patient ran out of the Allopurinol for a 3-4 days’ time frame last week, as he observes. Even, that could have resulted in the exacerbation. Currently, the medication is filled. No edema noted. Edema was not a finding even during the last 2 months, as SN notes indicate. Heart sounds were noted to be regular during the last 2 months. Blood pressure has been under decent control. Systolic blood pressure over the certification period varied between 100 – 142. Diastolic pressures varied between 60 and 86. Heart rate varied between 70 and 94 over the certification period. No episodes of any chest pain reported over the 60-day episode. Hyperacidity and GERD is reportedly under control. No exacerbation reported in recent times. Episodes of urinary and bowel incontinence still occur. Constipation is not a major issue with patient and bowel movements were reported to be quite regular. No UTIs were reported in the last 60-day episode. Patient reports small joints in the hands hurting, secondary to gout. Grips in the hands are weaker due to pain reported. Patient has a poor balance in BLE. Therapy evaluation was suggested by RN. But, patient denied it for now. Patient’s ability to open his pill container was checked by RN to see, if he is independent with it, in the wake of his exacerbation of gout and pain in the small joints of hands. Patient was able to do that with minimal difficulty. Patient was instructed upon fall and safety precautions during the assessment. Patient needs continued home health service for continuing education on gout prevention measures, medication compliance, control over urinary and bowel incontinence, and pain management.

#4

Reason(s) for Home Health Admission

• Exacerbation of Multiple Sclerosis
• Diffuse Body Aches and Spasms
• Poor Motor Coordination
• Multiple Falls
• Worsening Bladder and Bowel Incontinence

Patient is a 69-year-old female living in a senior living facility by herself. Patient has a past medical history of MS, OA, depression, hypothyroidism, and low vision. Dr. A is the neurologist. Patient missed her last appointment due to schedule conflicts. So, preauthorization form for Avonex was not signed. RN called the XXX specialty pharmacy at 1-xxx-xxx-xxxx at xx: xx and spoke to customer care representative ABC regarding the refill. The customer care representative ABC answered that the preauthorization was faxed to Dr. A’s office today and they are waiting to hear from the office. RN also called Dr. A’s office for follow-up on preauthorization. RN was told that they will reach out to the patient on the issue today afternoon. Patient reports diffuse spasms and shooting nerve pain in the limbs. Patient also reports pain in the left eye. Pain currently is varying between 2 – 6. Heart rate was elevated at 98 today. Patient requires assistance with administration of Avonex IM injections weekly and is unable to safely administer the shot herself due to poor fine motor control in her hands and low vision. Also, patient is forgetful with regards to use of her assistive device despite repeated instructions. Patient is at increased risk for fall. Patient also is having an exacerbation of MS, as the symptoms suggest, secondary to noncompliance with Avonex. Diffuse body aches, spasms, with left eye pain, and increased frequency of incontinence of bowel and bladder reported. So, patient is being recertified on continued home health services. Patient was instructed to practice deep breathing to prevent areas of atelectasis and lung collapse in the basal areas. No complaints of diarrhea, reflux or constipation reported. No UTIs reported in recent times. No falls reported in recent times. No hospitalizations in recent times. Patient has a very poor coordination on walking. Patient was noted to be noncompliant with walker use.