Nursing Paper Charting Examples: A Comprehensive Guide

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.

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