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    SKILLED NURSING CHARTING RECORD Neuro # Alert # Confused # Lethargic # Sedated # Agitated # Non-responsive Oriented: # Person # Place # Time Speech: # Clear # Slurred # Aphasia Respiratory 1. Rhythm: # Regular # Irregular # Short of breath on exertion Oxygen: # None # __ l / m # No Cough # Non-productive # productive breath Sounds:

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    SKILLED NURSING CHARTING RECORD Neuro # Alert # Confused # Lethargic # Sedated # Agitated # Non-responsive Oriented: # Person # Place # Time Speech: # Clear # Slurred # Aphasia Respiratory 1. Rhythm: # Regular # Irregular # Short of breath on exertion Oxygen: # None # __ l / m # No Cough # Non-productive # productive breath Sounds:

    Copyright:

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    Download as PDF, TXT or read online from Scribd
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    2K views1 page

    Charting

    Uploaded by

    berhanubedassa
    SKILLED NURSING CHARTING RECORD Neuro # Alert # Confused # Lethargic # Sedated # Agitated # Non-responsive Oriented: # Person # Place # Time Speech: # Clear # Slurred # Aphasia Respiratory 1. Rhythm: # Regular # Irregular # Short of breath on exertion Oxygen: # None # __ l / m # No Cough # Non-productive # productive breath Sounds:

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    of 1

    SKILLED NURSING CHARTING RECORD SHIFT D / E / N

    Neuro □ Alert □ Confused □ Lethargic □ Sedated □ Agitated □ Non-responsive


    Oriented: □ Person □ Place □ Time Speech: □ Clear □ Slurred □ Aphasia

    Respiratory Rhythm: □ Regular □ Irregular □ Short of breath □ Short of breath on exertion


    Oxygen: □ None □ __ l/m □ No Cough □ Non-productive □ Productive
    Breath Sounds: RUL __ RML __ RLL __ LLL __ LUL __
    1. Clear 2. Crackles 3. Wheezes 4. Diminished 5. Rhonchi

    Cardiac
    Rhythm: □ Regular □ Irregular
    Radial: RT □ Present □ Absent LT □ Present □ Absent
    Pedal: Rt □ Present □ Absent LT □ Present □ Absent
    Edema: □ None □ Present (□ 1+ □ 2+ □ 3+ □ 4+) Location: _______________

    GU Abdomen: □ Soft □ Firm □ Rounded □ Distended □Tender / Location: ________


    Bowel Sounds: □ Present □ Absent X___Quadrants C/O □ Nausea □ Vomiting □ Diarrhea

    Musculoskeletal
    Mobility: □ Full □ Limitations Describe: ____________________________________________
    Gait: □ Steady □ Unsteady Activity: □ Self □Assist □ Total
    HOB: □ Up _____ Deg. ROM: □ Self □ Assist

    Skin
    Color: □ Normal □ Cyanotic □ Pale Condition: □ Dry □ Moist
    Temperature: □ Cool □ Warm Integrity: □ Intact □ Not intact
    Skin Integrity Protocol: □ Yes □ No □Turned approximately every 2 hours □Turns Self

    Psych
    Affect: □ Calm □ Anxious □ Flat □ Confused □ Depressed □ Combative □ See Behavior documentation MAR
    Communication: □ Intact □ Impaired
    Involvement with plan of care: □ Active □ Refuses □ Dependent

    Pain □ Denies □ Location __________ Intensity (Scale 0-10) _________


    Pain Medication: □ Effective □ Non Effective (If ineffective, document in nurses notes)

    Nutrition
    Appetite: Good / Fair / Poor

    Safety
    Siderails: □ Full □ Half Transfers: □ Use lift □ 1 asst □ Total □ Independent
    Fall Risk Protocol: □ Yes □ No □ Call light in reach □ Low Bed □ Restraint

    Voiding Color: □ Yellow □ Amber □ Blooding □ Other _________


    Appearance: □ Clear □ Cloudy □ Sediment □ Odor □ Dysuria □ Frequency
    Catheter: □ Foley _____ □ Straight ___ □ See Intake and Output

    VITAL SIGNS: B/P _________ PULSE _______ RESP ______ TEMP _____

    DOCUMENT ANY ISSUES REQUIRING FURTHER EXPLANATION ON NURSES NOTES


    Medical Record No. Room/Bed Date Licensed Nurse’s Signature

    Patient Name Physician

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