Narrative Nursing Notes
A narrative note is a chronological written account of assessments, care and the patient's response, written in complete sentences rather than in labelled sections.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyContent status: Draft — not yet professionally reviewed.
Why it is structured this way
Narrative notes tell a story in time order. That makes them flexible for events that do not fit a checklist, but it also means the writer has to supply the structure: time, what was found, what was done, and what happened next. Without that discipline, narratives drift into vague or wordy entries.
When this may be used
- Events that do not fit a flowsheet, such as an unusual occurrence or a conversation with family.
- Settings or programs that use narrative charting as their main format.
- Supplementing flowsheet or charting-by-exception entries when more explanation is needed.
- Whether narrative notes are used, and how, depends on the organization's policy and EHR design.
Components
Time and context
Anchors the entry so readers know when events occurred.
What belongs here
- Time of the event or assessment
- Brief reason for the entry
What does not belong
- Times you did not observe
- Backdated or pre-written entries
Findings
Records what was observed, measured or reported.
What belongs here
- Assessment findings you actually obtained
- Patient statements, quoted when helpful
What does not belong
- Findings not assessed
- Opinions about the patient's character
Actions
Shows the care provided.
What belongs here
- Nursing actions you performed
- Care by others, attributed to them
What does not belong
- Care that has not happened yet
- Another person's care written as your own
Response and follow-up
Closes the loop.
What belongs here
- Patient response
- Reassessment
- Notifications actually made
What does not belong
- Assumed outcomes
- Speculation
Short fictional example
- Narrative
- 1330: Patient reports "I feel sick to my stomach." No emesis observed. Emesis basin placed within reach and head of bed raised per patient request. 1400: Patient states nausea is "a little better."
More detailed fictional example
- Narrative
- 0915: Patient used call light and asked for help to the bathroom. Patient states "I feel a little dizzy when I stand up." Assisted to sitting on edge of bed; patient sat for 1 minute before standing. Walked 10 feet to bathroom with gait belt and assist of one. Steady gait observed; no loss of balance. Patient voided and returned to bed with same assistance. 0925: Patient states dizziness "is gone now." Bed in low position, call light within reach. Patient reminded to call before getting up; patient said "OK, I will."
Annotated example
Notes on the detailed example above:
0915: Patient used call light…
— A time opens each part of the story so the sequence is clear.Patient states "I feel a little dizzy when I stand up."
— The patient's own words are quoted, which keeps subjective information separate from observations.Walked 10 feet… with gait belt and assist of one.
— Specific, measurable detail instead of "ambulated well."0925: Patient states dizziness "is gone now."
— The response is documented, not assumed.
Common mistakes
- Writing a long paragraph with no times, so the sequence is unclear.
- Using vague words such as "fine," "good day," or "tolerated well" without saying what was observed.
- Mixing personal opinions into the story.
- Leaving out the patient's response to care.
- Charting routine findings that were not actually assessed.
Good vs poor documentation
Weaker (fictional)
Patient had a good morning. Walked OK.
Stronger (fictional)
0915: Walked 10 feet to bathroom with gait belt and assist of one; steady gait, no loss of balance observed.
Why: The stronger entry says what was done, how, and what was observed.
Blank educational template
Narrative note: A chronological account in full sentences. Prompts only; nothing is prefilled.
- Time / context
- [Time of entry and reason for the note]
- What was observed or reported
- [Assessment findings actually obtained; patient statements in quotation marks]
- What was done
- [Nursing actions actually performed, and by whom if not you]
- Response and follow-up
- [Patient response, reassessment and any notification actually made]
Practice this format
- Practice Note Builder — write a practice note from a fictional scenario.
- Documentation practice questions
Related documentation guides
Sources
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association.
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College).
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax.
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.