HEAS 1000

STUDENT NAME (please print): Lilly and Nirali____________________________ID#__

_____

Client Care Record

Date Time Nurse’s Notes

10 Nov 1037 Received into care at 1000.Lying in bed with Documentation Guidelines:
2020
head of bed elevated 30*. Alert, oriented x4. Format:

Concerned with pain in “left hip”. Rates pain.  Permanent black/ blue ink
-----/10 States pain started when she tripped on  Correct Date format: Day
“rug 3 days ago”. Stated medicated cream Month Year (e.g. 07 Feb
2016)
relieves pain as well as well as Tylenol 500mg
 Time – use 24-hour clock
prn twice daily. Pain affects ADL’s with (no colons or semi colons)
sleeping. Diagnosed osteoarthritis 15 years  Signature (1st initial, last
ago, resulting in vision deterioration 3 years name and designation
(eg. J Smith SPN )
ago. Denies use of vitamins, supplements, and  Correct error appropriately
mood-altering drugs. States allergy to dust and (single line, initial, mistaken
entry )
pollen, causes itching and rhinitis. Relief from  No blank spaces at the end
of line or between entries
allergy from taking Claritin 1 tab. On  No abbreviations
assessment, vital signs taken, see flow sheet.  For sequential page
documentation, signature
Lying supine position, skin warm, pink, dry. at bottom of 1st page. On
second page, time, date
Facial expression is intact and relaxed. No and “continued”.
involuntary movement, shape and tone of Content:
muscle groups symmetrical, no masses or  Indicated how patient was
crepitation, no atrophy noted on palpation. found.
Contour smooth over left hip joint, no redness.  Indicated safety
Skin in hip warm to touch. States pain in left precautions (side rails &
call bell in reach?) How was
hip upon palpation. Pain in joint upon client left?

extension, flexion, internal and external  Did not use the word
rotation, and abduction and adduction. “patient” or “client” in
charting.
--------------------------------Lsterner, SPN
 Chronological/sequential
manner

 Subjective information-
what the client says about
herself or himself

 Accurate documentation
for inspection

May 17, 2018

HEAS 1000

 Accurate information for

palpation.
 Accurate information for
auscultation, or other key
systems.
 Correct spelling
 No double charting (do not
chart vitals unless
abnormal, chart “Vital signs
taken, see flow sheet”.
 Document what you have
done, not what you will do.

Date Time Nurse’s Notes

May 17, 2018

HEAS 1000

Jarvis, C. (2014). Physical examination & health assessment (2nd Canadian ed. p 66). Toronto, ON: Saunders Elsevier.
Retrieved from: http://studywithclpna.com/nursingdocumentation101/

May 17, 2018