MEDICINE CARDFRONT and BACK

EXAMPLE OF NARRATIVE CHARTING

DATE STAT ORDER/ TREATMENT 7-3 shift

June 7 am  Received lying on bed, with IVF of PNSS 1 Liter x 16 hours,

7, IV site @ right basilic vein, infusing well.
2021  With O2 inhalation at 2 L/min via nasal cannula.
 With foley catheter attached to urine bag draining to a
yellowish colored urine at 300 cc.
7:45  V/S checked and recorded as follows:
BP = 140/90 mm Hg
P = 89 b/min
R = 20 br/ min
T = 37. 1ᵒC / axilla
 Morning care rendered.
8  Oral medications administered
 Dr. E. Villanueva visited. Written orders carried out.
9:20  For chest x-ray PA view today.X-ray department informed
with request form given.
Diet as tolerated, low salt diet  Lunch served. No appetite to eat.
 Had taken a short nap.
Chest X-ray PA view 1:30  Done atXray room. Back to ward per wheelchair.
 Latest BP = 130/80 mm HG
3pm  Endorsed to NOD with same IVF on with 250 cc more to
infused, will due at 5pm.

Signature of student / C. I.

EXAMPLE OF ENDORSEMENT
Good afternoon maam( to nurse on duty).

I’m Eunice M. Gomez. Endorsing my patient Ms Ellen Cruz, with diagnosis of Gastritis.

 Has an IVFluid of PNSS 1 liter for 8 hrs., will due at 5pm , at the level of 250 cc.
 IV to follow is D50.3 NaCl 1 liter x 12 hrs, available.
 For whole abdomen ultrasound in am. NPO post midnight instructed.
 Dulcolax tab and suppository – already prescribed.
 Abdominal pain scale is 6 at 2:45 pm.
 Thank you.