HEAS 1000

STUDENT NAME (please print): ____________________________ID#__ _____

Client Care Record

Date Time Nurse’s Notes

Documentation Guidelines:
19 March 2021 1000 Recieved into care at 0900 resting in bed, sitting Format:
alert, oriented to person, place, time & self. Side rails up x2  Permanent black/ blue ink
 Correct Date format: Day
Month Year (e.g. 07 Feb
call bell in reach. Facial expressions relaxed, symmetrical
2016)
maintaining eye contact. Skin pink, consistent with genetic  Time – use 24-hour clock
(no colons or semi colons)
backgroud, even tone, intact, no lesions, no pallor or cyanosis noted.  Signature (1st initial, last
name and designation
well nourished, speech clear, no slurring, smooth & articulate (eg. J Smith SPN )
 Correct error appropriately
Responds appropriately to questions, no noted hearing deficit (single line, initial,
mistaken entry )
Well groomed, no noticeable body odour. No known allergies  No blank spaces at the end
of line or between entries
to medications, food, environment, contact or latex.  No abbreviations
 For sequential page
Vital signs taken see flow sheet. GCS completed see flow sheet. documentation, signature
at bottom of 1st page. On
Facial features symmetrical, no facial droop, no ptosis second page, time, date
and “continued”.
Denies numbness or tingling to extremities, no difficulty with swallowing noted Content:
 Indicated how patient was
fell off motorbike 2 days ago, pain to left hip. Sitting makes it worse found.
 Indicated safety
standing makes it better, describes as achy, throbbing, rates pain 7/10 precautions (side rails &
call bell in reach?) How was
Pain to left hip, no radiation, no treatment, feels she did something when she fell client left?
 Did not use the word
off her motorbike, wants pain 2/10, no other symptoms. “patient” or “client” in
charting.
Respirations easy, effortless, symmetrical, chest clear to  Chronological/sequential
manner
auscultation in all lung lobes, no adventitious sounds, denies cough.  Subjective information-
what the client says about
heart sounds regular S1, S2, no S3,S4 noted, no heaves or thrills, herself or himself
 Accurate documentation
Cap refill <2 seconds, edema +2 to feet and ankles noted, dorsalis and posterior tibial for inspection
 Accurate information for
pulse 2+, regular & strong, skin pink, warm & dry, no tenting, abdomen palpation.
 Accurate information for
flat, bowel sounds active x 4 quadrants, no pain to light palpation, last BM yesterday auscultation, or other key
systems.
eating well, no nausea or vomiting. Voiding regularly, urine clear yellow.  Correct spelling
 No double charting (do not
Advised to ring if any concerns. Left bed in lowest position chart vitals unless
abnormal, chart “Vital signs
side rails x 2 up, call bell in reach.----- KNickerson RN taken, see flow sheet”.
 Document what you have
done, not what you will do.

Aug 26, 2020 V1.20

HEAS 1000

Date Time Nurse’s Notes

Jarvis, C. (2019). Physical examination & health assessment (3rd Canadian ed.). Toronto, ON: Saunders Elsevier.
Retrieved from: http://studywithclpna.com/nursingdocumentation101/

Aug 26, 2020 V1.20