Why are you charting? How about this?
UTI? Pain, temperature, complaints, odor of urine, mentation, reaction to ABT, output, what else did you do?
V/S 98.2,68,14,112,58 98% saturation on room air. Has denied pain and verbalized no complaints. Urine remains with strong odor. Mentation at baseline for this resident. No reaction noted to prescribed ABT. UOP X 4 incontinent per usual. Fluids at bedside and encouraged with med pass. Nancy Nurse RN.
Wound. What, where, dimensions, description, complaints?
Resident has 4 x 3 cm skin tear to right forearm. Wound is dry and free from drainage, warmth, or odor. Edges well approximated, steristrips in place. Resident denies pain, stating that area is "sore".
Remember, it's not how much you chart, it's how you chart.