This is an example of a head-to-toe narrative assessment note. I have my first-semester nursing students start by writing out a narrative assessment on the clinical floor, before proceeding to any facility assessment flowcharts.
86 y.o. male admitted 10/01/09 for left-sided cva with right-sided hemiparesis. vs 37.4 c, hr 97, rr 22, bp 140/76.
Alert and oriented to person, place, day/ time, and situation; denies any pain or distress. Perrla.
Responds appropriately to verbal stimuli; no slurring of speech.
At risk for aspiration related to dysphagia; on thickened dysphagia diet.
Feeds self with assistance.
Skin acyanotic with loose turgor.
Mucous membranes moist and pink. negative jvd.
Respirations even, unlabored. breath sounds clear to auscultation throughout all lung fields. (if your patient is on o2, make sure you record the o2 rate and delivery system here, along with pulse ox readings).
Apical pulse regular rate and rhythm; s1, s2 noted. Abdomen soft & nondistended with bowel sounds active in all 4 quadrants.
Pink nailbeds with capillary refill less than 2 seconds in all extremities.
Peripheral pulses palpable in all extremities.
Moves all extremities.
Hand grips unequal: strong on left, weak on right.
Right arm has limited mobility due to weakness secondary to cva.
Has a 20 gauge saline lock to left lateral forearm.
Site is free from redness or drainage, with tegaderm dressing intact. (If your patient has an infusing iv, make sure you record the fluid and rate in your assessment).
Uses urinal, has occasional episodes of incontinence. urine clear yellow. No skin breakdown noted. ted hose on bilaterally.
Homan's sign negative bilaterally. feet cool, dry, intact, with thick toenails bilaterally. side rails up x 3, bed in low position. call bell within easy reach of left hand.
Instructed to call for any needs or to request assistance before attempting to get up. Verbalized understanding. Will continue to monitor closely. .... s.johnson, student nurse
Excellent resources concerning nursing documentation:
Practice Standard: Nursing Documentation
Ladies & Gentlemen of the jury, I present... the nursing documentation
Do's and Don'ts of Documentation
Documentation: Proactive Prevention of Litigation
8 Common Charting Mistakes To Avoid
Abbreviations: A Shortcut to Disaster