Example Narrative charting PDF

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Date 2-3-16 Time 0700 0730

1000 1020 1035 1035 1130 1200

Narrative Notes Received bedside report from Trena RN, assumed care. ………………..………R. Pecoraror RN Lying in bed eyes closed, easily awaken with verbal stimuli. Oriented to person and………. place, but confused about date and time. Successfully reoriented to date and time……….. Telem monitor in use, SR, HR = 76, no c/o cardiac related CP. BBS c expiratory wheezing to bilateral lower lobes, RR = 22, pulse ox = 97% on 2L NC, denies SOB. Productive cough of thick yellow sputum, c/o chest sore from coughing, rates 2/10. Encouraged to………….. increase po fluids, TCDB, and use I.S. to help loosen secretions. #20 jelco to R forearm…. with NS @ 125ml/hr c 400 TBA, no redness, swelling or tenderness to site. Large bruise noted to L hip, states ran into the table prior to admit. See 24 hour flowsheet for………… additional assessment…………………………………………………………………………………………………R.P. Leaking and swelling noted to IV site. D/Ced #20jel. from R arm, tip intact, pressure applied to site……………………………………………………………………………………………………………..R.P. #22jel. started to L hand x 1 attempt, IV flds restarted………………..……………………………..R.P. Addendum for 0730: Hycotuss 10ml po given for c/o cough……………………………………....R.P. Addendum for 0830: Verbalized cough relieved……………………………………………………......R.P. Resting quietly, eyes closed, respiration even and unlabored, SR up…………………………..R.P. Reported off the Halie RN……………………………………………………..…………………….………………R.P.

Date 2-3-16...