This is my second day of charting. We're at a nursing home and have same resident each week for now. This is for practice, we will be charting in the actual chart next week. How does this look/sound?
11/09/07 0710 Supine in recliner, resting /c eyes closed. Aroused easily, A&O x 3. T 97.9, P 78, R 20, BP 122/65. PERRL 3mm. AV fistula L upper arm bruit present, thrill bounding. Resps shallow, even, unlabored. Skin on face and chest pink, warm, dry & intact. Chest symmetrical. Lung sounds clear A&P bilaterally. Pulse Ox 98% on room air. Abdomen soft, round, non-tender on light palpation. Bowel sounds present x4. LBM 11/8/07, large, soft, brown. Ap pulse 78, irregular. States "An aide bumped me on my pacemaker yesterday and it really hurts. It hasn't felt right since then." C/O pain 3/10 over pacemaker site. Reported to charge nurse. UEx2 pale, warm, dry. Radial pulses thready. L hand shows 1+ pitting edema. Denies paresthesia and pain, no paralysis noted in UE. Hand grasp = bilaterally. Ankles purple, cracked, peeling from ankles approximately 20 cm up and around the circumference of both legs. Tibial and pedal pulses non-palpable bilaterally. LE show 2+ pitting edema bilaterally. Cap refill
0900 Up in w/c. Feeding self independently. Denies needs. Call light in reach.-------J Doe SN
1100 Participating in activity in dining hall. Denies needs. Report off to charge nurse. J Doe SN