Nursing paper charting is the process of recording patient care and observations on paper. It is an essential part of the nursing process and helps to ensure communication between healthcare professionals. Nursing paper charting notes should be clear, concise, and objective. They should document all relevant information about the patient’s condition, care provided, and responses to care.
There are many different types of nursing paper charting notes. Some common examples include:
- Medication administration: This type of note documents the date and time of medication administration, the name of the medication, the dosage, the route of administration, and the signature of the nurse.
- Vital signs: This type of note documents the patient’s blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation.
- Pain assessment: This type of note documents the patient’s location of pain, type of pain, intensity of pain, onset of pain, duration of pain, and aggravating and relieving factors.
- Neurological assessment: This type of note documents the patient’s level of consciousness, orientation, pupillary response, motor strength, and sensory function.
- Respiratory assessment: This type of note documents the patient’s respiratory rate, depth of respirations, effort of respirations, and lung sounds.
- Cardiovascular assessment: This type of note documents the patient’s heart rate, blood pressure, rhythm, and heart sounds.
- Gastrointestinal assessment: This type of note documents the patient’s bowel sounds, abdomen tenderness, and abdominal distention.
- Urinary assessment: This type of note documents the patient’s urine output, color of urine, and clarity of urine.
- Skin assessment: This type of note documents the patient’s color of skin, warmth of skin, moisture of skin, and skin integrity.
- Psychosocial assessment: This type of note documents the patient’s mood, affect, behavior, thought process, and coping mechanisms.
- Discharge planning: This type of note documents the patient’s understanding of their condition, the patient’s understanding of their discharge medications, the patient’s ability to perform self-care activities, and the patient’s support system in place at home.
In addition to these common examples, there are also many advanced nursing paper charting notes that can be used. For example, focused assessments are used to assess specific body systems or problems. Flowsheets are used to track changes in a patient’s condition over time. And nurses’ notes are narrative summaries of nursing care provided.
Benefits of using nursing paper charting examples
There are many benefits to using nursing paper charting examples. First, they can help nurses to save time and improve efficiency. Second, they can help to ensure that all relevant information is documented. Third, they can help to improve communication between healthcare professionals. And fourth, they can help to reduce the risk of errors.
Tips for writing effective nursing paper charting notes
When writing nursing paper charting notes, it is important to keep the following tips in mind:
- Be objective and factual.
- Be clear and concise.
- Use correct medical terminology.
- Document all relevant information, including the patient’s subjective and objective data, your assessment, and your interventions.
- Sign and date all of your entries.
Common nursing paper charting examples
Medication administration
Example:
Date and time: 2023-10-13 12:13
Name of medication: Acetaminophen 500 mg
Dosage: 1 tablet
Route of administration: Oral
Signature of nurse: Jane Doe, RN
Vital signs
Example:
Date and time: 2023-10-13 12:13
Blood pressure: 120/80 mmHg
Heart rate: 80 bpm
Respiratory rate: 16 breaths/minute
Temperature: 98.6°F
Oxygen saturation: 98% on room air
Pain assessment
Example:
Date and time: 2023-10-13 12:13
Location of pain: Right lower quadrant of abdomen
Type of pain: Sharp, cramping Intensity of pain: 7/10
Onset of pain: 1 hour ago
Duration of pain: Continuous
Aggravating and relieving factors: Aggravated by movement, relieved by rest
Neurological assessment
Example:
Date and time: 2023-10-13 12:13
Level of consciousness: Alert and oriented x 4
Pupillary response: Equal, round, and reactive to light and accommodation
Motor strength: 5/5 in all extremities
Sensory function: Intact in all extremities
Respiratory assessment
Example:
Date and time: 2023-10-13 12:13
Respiratory rate: 16 breaths/minute
Depth of respirations: Normal
Effort of respirations: Unlabored
Lung sounds: Clear to auscultation bilaterally
Cardiovascular assessment
Example:
Date and time: 2023-10-13 12:13
Heart rate: 80 bpm
Blood pressure: 120/80 mmHg
Rhythm: Regular
Heart sounds: Normal S1 and S2 heart sounds, no murmurs
Gastrointestinal assessment
Example:
Date and time: 2023-10-13 12:13
Bowel sounds: Active in all four quadrants
Abdomen tenderness: Mild tenderness in the right lower quadrant
Abdominal distention: None
Urinary assessment
Example:
Date and time: 2023-10-13 12:13
Urine output: 100 mL in the past hour
Color of urine: Pale yellow
Clarity of urine: Clear
Skin assessment
Example:
Date and time: 2023-10-13 12:13
Color of skin: Pink
Warmth of skin: Warm
Moisture of skin: Dry
Skin integrity: Intact
Psychosocial assessment
Example:
Date and time: 2023-10-13 12:13
Mood: Anxious
Affect: Appropriate to mood
Behavior: Cooperative
Thought process: Linear and logical
Coping mechanisms: Uses relaxation techniques
Discharge planning
Example:
Date and time: 2023-10-13 12:13
Patient’s understanding of their condition: The patient understands that they have appendicitis and will require surgery.
Patient’s understanding of their discharge medications: The patient understands that they will need to take antibiotics for 10 days after surgery.
Patient’s ability to perform self-care activities: The patient is able to perform all self-care activities independently.
Patient’s support system in place at home: The patient has a spouse who will be able to help them with care after surgery.
Advanced nursing paper charting examples
Focused assessments
Focused assessments are used to assess specific body systems or problems. For example, a focused respiratory assessment might be performed on a patient with pneumonia. A focused neurological assessment might be performed on a patient who has suffered a stroke. And a focused cardiovascular assessment might be performed on a patient with heart failure.
Flowsheets
Flowsheets are used to track changes in a patient’s condition over time. For example, a vital signs flowsheet might be used to track a patient’s blood pressure, heart rate, respiratory rate, and temperature every hour. A pain assessment flowsheet might be used to track a patient’s pain level every two hours. And an intake and output flowsheet might be used to track a patient’s fluid intake and output every four hours.
Nurses’ notes
Nurses’ notes are narrative summaries of nursing care provided. Nurses’ notes should be comprehensive and include all relevant information about the patient’s condition, care provided, and responses to care. Nurses’ notes should also be chronological and include the date and time of each entry.
Conclusion
Nursing paper charting is an essential part of the nursing process. It helps to ensure communication between healthcare professionals, document patient care, and reduce the risk of errors. Nursing paper charting examples can help nurses to save time and improve efficiency when writing charting notes.
