Examples of Nursing Documentation

  1. 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. 8 Comments

  3. by   VickyRN
    Perhaps this link will be of help to you

    http://allnurses.com/forums/f205/nur...on-168921.html
  4. by   MARIAN202
    sample Charting Entry:
    date:
    time:
    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
  5. by   mcneillmama3
    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.
  6. by   kimikia
    I am a new nurse and am having difficulty with documentation. Please help me.
  7. by   flutist
    Pt received in bed sleeping. Easily awoken to writers voice. States he slept well last night. Pt alert x4. Vitals done. 124/65-70-18-36.5-96% RA. Lungs asculated with good air entry bilaterally to bases. No wheeze heard. Resps even and unlaboured. Assisted pt to sit at side of bed. No voiced c/o at present. FlutistRN
  8. by   MunoRN
    Quote from kimikia
    I am a new nurse and am having difficulty with documentation. Please help me.
    Any problems in particular?
  9. by   kimikia
    no not in particular, just basic documenting. What to say how much to say.
  10. by   Oh'Ello
    This is difficult because I think a lot of us engage in electronic charting where you choose responses from dropdown menus or chart by exception

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