Examples of Nursing Documentation

  1. 0
    Looking for some websites that may have some examples of nursing documentation, charting, or nurses notes. If anyone knows of any please let me know. Thanks.

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  2. 3 Comments...

  3. 0
    Perhaps this link will be of help to you

  4. 2
    sample Charting Entry:
    temp 98.4, Radial Pulse 72, Strong And Regular. Respirations Deep And Regular At 14 Per Min., Bp 124/66. Oriented X4. Perrla, Neck Veins Flat At 45 Degree Angle. Apical Pulse S1,S2 Clear Without Rubs Or Murmurs. Radial And Pedal Pulses Strong And Regular Bilaterally At 70 Per Min. Hand And Leg Strength Strong Bilat. Capillary Refill Hands And Toes Returns 1 Sec. Bilat. Skin Tugor Returns 1 Sec. Skin Warm, Color Pink(pt Specific Color). Lung Sounds Clear Bilaterally To Auscultation With Good Air Flow. Right Middle Lobe Clear. Bowel Sounds Present And Active 4 Quadrants. No Peripheral Edema Extremities Or Sacrum. No C/o Pain. Skin Intact Without Breakdown. No Pain On Dorsiflexion.
    signature And Title.

    hope The Is Of Some Help
    Last edit by MARIAN202 on Jan 8, '07
    Farideh and LVNtoBSN like this.
  5. 0
    Check out this website. I too was wanting to refresh on nursing documentation since I have been using pre printed forms for the past 8 years. This looks really good:
    a nursing documentation template.

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