Nursing note for beginner LPN, my first note..opinions?

[aloveless88]

This is my first semester for LPN, I am writing my nursing note, it is based off a physical assessment on another class mate. opinions on how this looks? Be gentle lol:)

08/29/2014 0800, Female, vs. 97.8 F oral, hr 88, bp 138/92, o2 98% room air. weight 150lbs. Alert and oriented x3. speech clear, perria, responds to verbal stimuli, denies pain. grip strength equal, MAE X4, skin pink, warm, dry. elastic turgor. Mucous membrane clear and intact. Negative JVD, trachea midline, respirations clear, unlabored. Lung sounds clear through ausculation. Abdomen soft, nondistended, with bowl sounds in all 4 quadrants. Pink nail beds, capillary refill greater 2 seconds. Peripheral pulse papable in all extremities. Visually impaired, glasses required. Independent with feeding. Independent with bowel, bladder. Urine clear, yellow. Skin intact, negative breakdown. Will continue to monitor------------------------------------------------------------------------------A.Loveless PN Student

[sallyrnrrt, ADN, RN]

moves all four extremities

[edmia, BSN, RN]

Good job. Just one thing: you say she's alert and oriented and later on mention she responds to verbal stimulus. I would use the verbal stimulus thing only with a patient who is sleeping, or lethargic, or somehow with a changed mental status to convey that they do respond and didn't need stronger stimulus to wake up. If I say AA&O, then that's it, no need to stimulate them.

And just FYI, Homans sign does not have much diagnostic value according to evidence (many false positives), so it's really not recommended but if that's what your instructor wants you to document, leave it in.

[poppycat, ADN, BSN]

moves all four extremities

Thanks, I was having a senior moment with that, too.

[BBRANRN2013, ASN, RN]

Don't write will continue to monitor - will you be there every shift to monitor this patient? This is what I was told! If it's not right feel free to correct me:-)

[abbnurse]

Thanks, I was having a senior moment with that, too.

So was I ! I was glad to see that amoLucia asked the question just as I was searching my memory for that one....

[kbrn2002, ADN, RN]

If your instructor likes "continue to monitor" go ahead and leave it in. But in real world charting we haven't used the phrase "continue to monitor" for a long time, are you really going to be there to continue to monitor? A better ending note would be "proceed to plan of care" or something along those lines.

As I am sure somebody else must have mentioned, capillary refill greater than 3 seconds would definitely require follow up, are you sure you didn't mean capillary refill less than 2 seconds? Otherwise, not knowing what particulars your instructor likes, it looks pretty good to me.

[APRN., DNP, RN, APRN, NP]

You've displayed some strong work. My first nursing instructor told me to "Paint a picture with words".

.....Now it's clicking, typing, and selecting from a drop down menu. :)

However, I think it's still important to demonstrate fundamentals in written format.

[PomMom65]

Good work. I would mention the apical pulse and if it was regular or irregular.

[cowboy up]

Continuing to monitor is unnecessary it's kind of stating the obvious