BRITISH COLUMBIA HEALTH

AUTHORITY Patient’s label goes here

Nursing (or Interdisciplinary) Progress (or
Integrated) Notes

DATE & FOCUS D NOTES

TIME A
R
P
May 8, Nursing D Received for care at 07:30 lying in bed, resting but easily awakened when
2019 at Initial name called and shoulders shook. Ox3 to time, place, person. Calm and
0750 Head-to- cooperative. Pupils equal and reactive to light (PERRL). Resps appears easy
toe and regular on RA. No WOB nor accessory muscles use noted. Stated no SOB.
Assessment No coughing. Chest clear. Good a/e bilaterally on auscultation. No adv.
sounds noted on auscultation. Afebrile. VSS (or VS within normal limits)
CWMS adequate to all 4 extremities. No CP. No dizziness. S1S2 intact on ausc.
PPP x 4, regular, 2+ on palpation (or radial & pedal pulses regular, 2+ on palp)
Skin dry, warm, pink, intact. Cap refill 2-3 sec. No pitting edema to
extremities. Abdo flat. BS x 4Q. Soft and no tenderness on palpation.
LBM Nov 22, 2016 (or 1/7 ago); normal per patient, no blood. No N/V/D.
States no abnormalities to urination (No dysuria/hematuria/foul urine).
#22 peripheral IV to right hand in-situ, no S/S of infection/infiltration. Good
Skin turgor. Oral cavities/tongue moist. No headache. Strong and equal
strength and normal movement to all extremities. Bedside safety check
done. Bed alarm on. No major concerns noted currently. Awaiting Psych to
see--------------------------------------------------------------------------------- RClover (RN)
09:00 RPN D No visual, auditory, or tactile hallucinations. No suicidal ideations or plans.
Assessment No homicidal ideations. Last EtOH was Nov 22, 2016 at 22:50, had 4 mickeys
of whiskey. Denies other recent substance use. See RPN Intake Assessment
Flowsheet----------------------------------------------------------------------- Asmith (RPN)
May 8 Pain D States 8/10 constant throbbing generalized headache. No blurry vision or
2019 at other vision changes. Ox3. No N/V. No photosensitivity. PERRL –---- SLee (RN)
09:30 A MRP Hospitalist informed of patient’s pain. New medication order rec’d for
pain – Tylenol 650mg PO given. Will continue to monitor. -------------- SLee(RN)
10:30 Pain R Pt states headache is “all gone now.” Will continue to monitor. No other
major concerns noted/voiced. --------------------------------------------- SClover (RN)
11:15 VSS D VSS. No WOB/SOB noted. No changes since last assessment. ----- SClover (RN)
12:45 Safety D Resps appears easy, regular on RA. No CP. No hallucinations. No suicidal or
Check homicidal ideations. No acute distress noted/voiced. No changes since last
assessment. ------------------------------------------------------------------- Asmith (RPN)
13:30 Med Clear D Per hospitalist, pt medically cleared for psych. PCC and Psych aware. – SL (RN)
15:10 Transfer D Pt to be transferred to Psych Ward 4S. Report given to RPN of 4S. Pt informed
of transfer. Awaiting for bed at 4S to be ready. ----------------------- SClover (RN)
16:00 Psychiatrist D Psychiatrist Dr. Psych in to see and speak to patient. No new orders received
currently ----------------------------------------------------------------------- ASmith (RPN)

SAMPLE CHARTING_WHSU_201920
 BRITISH COLUMBIA HEALTH
AUTHORITY Patient’s label goes here
Nursing (or Interdisciplinary) Progress (or
Integrated) Notes

DATE & FOCUS D NOTES

TIME A
R
P
May 8, Head-to-toe D Received for care at 19:30 in bed, eyes closed, appears to be resting. Pt opened
2019 @ Assessmt: eyes spontaneously when name called. Daughter by bedside. Safety check done.
2030 CNS Ox2 to place and person. Thought it was year 2000, patient re-oriented to time.
Calm. Cooperative. No blurry vision. PERRLA. Answers questions appropriately.
Resp D Resps slightly shallow and appears slightly laboured. RR = 24. SpO2 90% on 2L O2
A via NP. Writer increased O2 to 4L via NP to keep sats above 93% – Will monitor
SpO2 and titrate O2 as needed. No accessory muscles noted as this time. States
feeling slightly SOB. No audible wheezing. Occ non-productive cough per pt.
Decreased a/e bilaterally, crackles heard on auscultation in all quadrants.
Circulation D Afebrile. Other than RR and SpO2, other VSS (See VS Flowsheet). Denies CP.
Denies dizziness. PPPx4, 2+ to radial pulses but 1+ to pedal pulses bilaterally.
2+ pitting edema noted to bilateral lower legs and feet. Cap refill <2sec to upper
extremities but 3sec to lower extremities. Skin dry, pink, intact, warm. Denies
dizziness. Decreased strength to all extremities. No numbness/tingling voiced.
GI/GU D Abdo round, BS x 4Q but slightly hypoactive. No tenderness on palpation. ---------
Voices slight nausea, no vomit/diarrhea. Writer offered anti-emetic meds per
Doctor’s orders but patient states “I don’t want any right now.” LBM 4/7 ago,
bowel protocol initiated (See Bowel Care Flowsheet). #14F foley cathether --------
in-situ, draining clear yellow urine; no concerns voiced by patient. ----- WLin(RN)
Saline Lock D #20g Saline-lock in-situ to R forearm. No s/s of infection or infiltration. Flushed
per policy and is patent. ------------------------------------------------------------ WLin (RN)
Safety Check D Bed alarm on. No other major concerns noted nor voiced by pt/daughter. ---------
--------------------------------------------------------------------------------------------- WLin (RN)
2050 Resp/O2 D RR = 20. SpO2 at 94% on 4L O2 via NP. Patient states “still feels slightly SOB”
Will continue to monitor and titrate O2 as per physician’s orders ------- WLin (RN)

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Common Charting Abbreviations You May See

ABBREVIATIONS MEANINGS
Rec’d Received
Ø No, none
Δ (This is the uppercase Greek Change
alphabet ‘Delta’)
With (In medicine, we don’t use w/ to symbolize with)
C̅ (This is the Lain word ‘with’) (ie: take meds with water = take meds C̅ water)
Ox3 Oriented x3 = Oriented to time, place, person
HOB Head of bed
O2 Oxygen
RA Room air
NP Nasal prongs
Resps Respirations
SOB Short of breath
WOB Work of breathing
GAEB = Good a/e bilaterally Good air entry bilaterally
CWMS Colour, warmth, movement, sensation
CP Chest pain
VSS Vital signs stable
S1S2 S1 S2 heart sounds
PPP x 4 Peripheral pulses present x 4 extremities
LBM Last bowel movement
BS x 4Q Bowel sounds x 4 quadrants
N/V/D Nausea/vomiting/diarrhea
IV Intravenous
S/S Signs and symptoms
EtOH Ethanol → thus alcohol
1/7 One day
1/7 ago One day ago
1/52 One week
1/12 One month
I&O Ins & Outs (usually means fluid balance)
D/C **careful of its potential Discontinue (ie: IV fluid or a medication) or discharge (ie: discharge
double use** home)
R/A Re-assessment
R/O Rule out
d/t Due to
#12F foley catheter #12 French (this is the size) foley catheter
#22g peripheral IV catheter #22 gauge (this is the size) peripheral IV catheter
D&I Dry & Intact

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