Nurses Narrative Note (Obstetrical Context)

Introduction to Nurse’s Narrative Note

 
A narrative note is one of the simplest and most traditional methods of nursing documentation. It records patient information in the form of a story-like paragraph, written in chronological order, and describes the patient’s condition, observations, interventions, and responses. Unlike structured formats (such as SBAR or SOAP), the narrative note allows nurses to capture the patient’s experience in detail, including both subjective statements and objective findings.
In the Indian hospital context, narrative notes are commonly used to:
•     Document patient complaints and concerns in their own words.
•     Record nurse’s observations such as vital signs, behavior, and physical findings.
•     Note actions taken (e.g., informing the doctor, administering medication, providing education).
•     Describe the patient’s response to interventions.
This style of documentation ensures continuity of care, supports communication among the healthcare team, and provides a legal record of nursing practice.

Example: 

Patient expressed, “I am anxious about this delivery because during my last cesarean I had severe pain and difficulty with spinal anesthesia.” Patient observed with tense posture and tearful voice. Informed obstetrician, Dr. Mishra, regarding patient’s prior adverse experience. Discussed anesthesia alternatives with anesthesiology team and pain-control strategies for labor/cesarean. Emphasized importance of early mobilization for uterine involution and prevention of complications. Encouraged patient to promptly report pain levels and reassured that pain can be effectively managed while ensuring safety for both mother and baby.

📌 SBAR Format
•     S (Situation): Patient verbalized fear regarding upcoming delivery. Nurse noted muscle tension and tearful, distressed tone.
•     B (Background): Patient fearful due to previous cesarean experience with spinal anesthesia and severe postoperative pain.
•     A (Actions taken): Informed obstetrician, Dr. Mishra, of patient’s prior experience. Coordinated with anesthesiology team to discuss anesthesia alternatives and multi-modal pain-control options. Educated patient on importance of early mobilization for recovery and maternal health. Encouraged open communication about pain levels and medication needs.
•     R (Recommendation): Monitor pain levels every 4 hours post-delivery. Provide nonpharmacologic pain relief (breathing exercises, positioning, warm compress) along with prescribed analgesics. Offer emotional support and reassurance regarding maternal–fetal safety.

📋 SOAP Format
•     S (Subjective): Patient stated, “I am worried about this delivery because last time I had a bad reaction to spinal anesthesia and severe pain after cesarean.”
•     O (Objective): Patient observed with tense muscles, tearful eyes, and anxious voice.
•     A (Assessment): Anxiety related to prior cesarean anesthesia and postoperative pain.
•     P (Plan): Informed obstetrician, Dr. Mishra, of patient’s prior experience. Discussed anesthesia alternatives and pain-control strategies with anesthesiology team. Reinforced importance of early mobilization for uterine recovery. Encouraged patient to report pain levels and reassured that pain is manageable.

📑 PIE Format
•     P (Problem): Patient expressed fear of delivery due to prior cesarean anesthesia reaction and postoperative pain. Observed muscle tension and tearful voice.
•     I (Intervention): Notified obstetrician, Dr. Mishra. Coordinated with anesthesiology team to discuss anesthesia alternatives and pain-control measures. Educated patient about benefits of early mobilization for maternal recovery. Encouraged communication of pain levels and medication needs.
•     E (Evaluation): Patient reported feeling reassured and expressed willingness to inform nursing staff about pain.

📂 Focus/DAR Charting
•     D (Data): Patient verbalized fear of delivery due to previous cesarean anesthesia reaction and severe postoperative pain. Observed tense muscles and tearful voice.
•     A (Action): Informed obstetrician, Dr. Mishra, of patient’s prior experience. Coordinated with anesthesiology team to discuss anesthesia alternatives and pain-control strategies. Educated patient on importance of early mobilization for maternal recovery. Encouraged communication of pain levels.
•     R (Response): Patient stated feeling “relieved” and acknowledged importance of informing nurses about pain.
•     P (Plan): Assess pain every 4 hours post-delivery. Provide nonpharmacologic pain relief (breathing techniques, positioning, warm compress) and administer prescribed analgesics as needed. Offer emotional reassurance regarding maternal–fetal wellbeing.