Examples of Nursing Documentation

Perhaps this link will be of help to you :)

https://allnurses.com/forums/f205/nursing-documentation-168921.html

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 this is of some help

I am a new nurse and am having difficulty with documentation. Please help me.

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

I am a new nurse and am having difficulty with documentation. Please help me.

Any problems in particular?

No, nothing in particular, just basic documenting. What to say and how much to say?

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.