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Discussion

nurse's note sample?

hey everyone.....i wanted to see if anyone ever had a sample nursing note that they used for reference in what they wrote? we have to do a DAR note in my facility and I didnt get alot of experience in school with doing notes....so starting my GN job i seem to forget things to include.....

if anyone has a sample of a general note that they use + or - the add ins depending on the pt until I get the hang of it:uhoh3:...i know to go by systems but it seems like i end up colliding them somehow...if anyone has any suggestions that would be GREATLY appreciated thanks!!

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Report received, walking rounds complete, orders reviewed. Assessment complete per flowsheet. AA&O x X. #8 ETT @ 24cm at teeth. breath sounds clear and equal bilaterally. FIO2 60%, SIMV, PEEP 10 (and so on with resp.). Respirations even and unlabored. S1, S2 audible with no murmur, s3 or s4 noted. Sinus tach @ 127 per monitor. Mediastinal dressing d/i. radial pulses 3+ on right. L radial art line s s/sx of infection. pedal pulses 2+ bilaterally, abd soft and round. bowel sounds active x4. No apparent distress noted at this time, oral care given. family update given. dopamine @ 20mg, midazolan @ 3, fentanyl @ 200mcg. L TLC subclavian patent, + blood return, no s/sx of infection. R Cordis with PA line in place. no s/sx of infection. R AC PIV # 16g s s/sx of infection. flushes easily, + blood return. NGT to LIS, placement verified by auscultation. bed in low position. Will continue to monitor.

That is just a quick rundown of my opening narrative. Then I just chart a simple

"Assessment per flowsheet, oral care given. No apparent distress noted" type note q2h and PRN as changes occur through out my shift.

Hope this helps.

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