nurse's note sample?

  1. hey everyone.....i wanted to see if anyone ever had a sample nursing note that they used for reference in what they wrote? we have to do a DAR note in my facility and I didnt get alot of experience in school with doing starting my GN job i seem to forget things to include.....
    if anyone has a sample of a general note that they use + or - the add ins depending on the pt until I get the hang of it...i know to go by systems but it seems like i end up colliding them somehow...if anyone has any suggestions that would be GREATLY appreciated thanks!!
    Last edit by kell1566 on Jul 12, '07
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    About kell1566

    Joined: Feb '06; Posts: 35; Likes: 3


  3. by   meandragonbrett
    Report received, walking rounds complete, orders reviewed. Assessment complete per flowsheet. AA&O x X. #8 ETT @ 24cm at teeth. breath sounds clear and equal bilaterally. FIO2 60%, SIMV, PEEP 10 (and so on with resp.). Respirations even and unlabored. S1, S2 audible with no murmur, s3 or s4 noted. Sinus tach @ 127 per monitor. Mediastinal dressing d/i. radial pulses 3+ on right. L radial art line s s/sx of infection. pedal pulses 2+ bilaterally, abd soft and round. bowel sounds active x4. No apparent distress noted at this time, oral care given. family update given. dopamine @ 20mg, midazolan @ 3, fentanyl @ 200mcg. L TLC subclavian patent, + blood return, no s/sx of infection. R Cordis with PA line in place. no s/sx of infection. R AC PIV # 16g s s/sx of infection. flushes easily, + blood return. NGT to LIS, placement verified by auscultation. bed in low position. Will continue to monitor.

    That is just a quick rundown of my opening narrative. Then I just chart a simple

    "Assessment per flowsheet, oral care given. No apparent distress noted" type note q2h and PRN as changes occur through out my shift.

    Hope this helps.
  4. by   luckystudentnurseRN
    this was good. thanks