NURSING CARE DOCUMENTATION
Student ____________________________ Date _________ Time: _________ Client Initials _________ Room # ______
Clinical Site: _____________________________________
Circle Appropriate Quarter: Days – Q1 Q2 Q3 Q4
Evening – Q2 Q3 Q4 Q5 Q6 Q7
DATA COLLECTION
Instructions: This assignment will guide you through the nursing process of data collection, problem identification, planning
your intervention, and evaluating the effect of your actions on the patient’s problem or need. Collect and record data that
describes your assigned patient as carefully and completely as possible. Data recorded in the Patient History/Information
section does not have to be restated in the body of the nursing notes unless it is related to an identified problem/need.
Areas of Focus and Possible Findings
Patient
History/Information
Note: Do not leave any
blanks. If information is not
available or applicable, write
N/A. This data is collected
from the patient’s chart
and/or from the patient or
family member.
Admission Date: ____________
Post op day: ____
Admission Diagnosis: __________________________________
Code Status:__________ Date of birth: ____________ Age: ___ Gender: ___
Food and drug allergies: _____________________________________________________________
Speech: _________ Hearing: _____________ Vision: _____________ Occupation: ___________
Surgical Hx: _______________________________________________________________________
Co-morbidities: ____________________________________________________________________
Recreational Drug Use: ________________________
Drinking (alcohol): __________________
Smoking: __________ Years: ____________ Pks/day: __________
Diet ordered: ________________________ Fluid requirements: ____________________________
Activity of daily living: ______________________________________________________________
Treatments:_______________________________________________________________________
Lab: WBC ________ RBC ________ HGB ______ Hct _______ Platelets _________ Na+ _______
K+ _____ Cl- ______ CO2 ______ Glucose ______ BUN ______ Creatinine _______ PT ______
PTT _____ INR _____ Ca++ ______ Mg++ ______
Diagnostic tests: _____________________________________________________________________
IV site: _____________________ Solution: ______________________ Rate: __________________
Precautions: ____________________________
Reviewed June 2013/JETF
Isolation: ______________________________
PHYSICAL ASSESSMENT
Instructions: The Vital Signs and Physical Assessment section of this document is to be used to develop your ability to perform
a physical assessment. Assessment data is one of the nurse’s tools used to identify Patient Problems. This assessment
guideline provides “basic” elements of assessing each system. Refer to the systems assessment guide for a more comprehensive
review.
Vital Signs
Neurological
Assessment
Note: Must write out
descriptors, abbreviations
not acceptable.
Temp _____ Pulse ____ Resp _____ Blood Pressure __________ _Pain ________ O2 SAT ______
Level of consciousness:_____________________ Orientation:_______________________________
Memory: _______________
Affect: ____________________ Speech: ______________________
Pupil Reaction:_______________________
Extra ocular Movement: ______________________
Motor Function:_________________________ Sensory Function:___________________________
Musculoskeletal
Assessment
Posture: ____________________________
Gait: _______________________________________
Strength of extremities: _____________________________________________________________
Joints: __________________________ Range of Motion: __________________________________
Integumentary
Assessment
Skin Appearance: ____________________ Temp: __________ Nail beds: ____________________
Mucous Membranes:____________ Turgor: _______________ Edema:_______________________
Lesions:___________________________________________________________________________
Pressure Ulcers: ____________________________________________________________________
Cardio/Peripheral
Vascular Assessment
Apical Pulse:___________ Peripheral Pulses:____________________________________________
Capillary Refill: ______________________
Arterial Deficiency Legs: ______________________
Venous Deficiency Legs: _____________________________________________________________
Respiratory
Assessment
Chest Shape: __________________ Oxygen:__________________ Delivery Route: _____________
Respiration Rate: _________ Rhythm: _____________ Effort: _____________________________
Lung Sounds: ______________________ Cough: _______________ Secretions: ________________
Gastrointestinal
Assessment
Diet: _________________________ Abdomen Shape:_____________________________________
Bowel Habits : ____________ Bowel Sounds: ______________________ Weight: _____________
Swallowing Ability:________________ GI Meds: ________________________________________
N/V: __________ Heartburn: _____________ Past Surgical Hx: __________________________
Genitourinary
Assessment
Urine Appearance: _____________________________ Output Amount:______________
Urinary elimination problems: _______________________________________________________
Catheter:______________________ Past Surgical Hx: _____________________________________
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Psychosocial
Assessment
Coping Mechanisms:_______________________ Expectation for recovery:____________________
Involvement in decision making: ________________Concerns/fears:__________________________
Support system:_______________________________________________________________
MEDICATIONS
Instructions: In the Medication section, list the medications that your patient is taking. This section is provided as a means of keeping
up with the times medications are to be given and help with building your knowledge about the drugs and their actions.
Medication
Ordered Dose
Classification
Nursing Implications
(Need to know before giving)
Time
Due
CLIENT PROBLEMS/PLANNED INTERVENTIONS
Instructions: Up to this point you have been collecting information about your patient. Review the data and identify problems or needs
the patient has that interfere with his/her healing process or ability to function at his/her optimum level. Document what you will do in
caring for the patient to help alleviate his/her problem(s)/need(s) (example: medicate, based on prescribed orders, for pain management).
Please note that your instructor may require a different number of problems and/or interventions as appropriate for your patient’s
condition or situation.
Problem/Need #1:___________________________________ Related to:________________________________________________
Intervention/Action Taken:______________________________________________________________________________________
_____________________________________________________________________________________________________________
Problem/Need #2: ___________________________________ Related to:________________________________________________
Intervention/Action Taken:______________________________________________________________________________________
______________________________________________________________________________________________________________
Problem/Need #3: ___________________________________ Related to:________________________________________________
Intervention/Action Taken:______________________________________________________________________________________
_____________________________________________________________________________________________________________
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Problem/Need #4: ___________________________________ Related to:_________________________________________________
Intervention/Action Taken:______________________________________________________________________________________
_____________________________________________________________________________________________________________
NURSING CARE NOTES
Instructions: The Nursing Care Notes section is a narrative documentation using the patient data to address the
identified problems/needs. You are to answer the questions: what is the problem, what was done to address the problem; what
affect did the intervention have on the problem. Nursing notes are legal documentation which address the evolution of the
patient’s condition and response to nursing care.
The patient’s vital signs should be written in the initial body of the Nursing Care Notes. Document the patient’s problem, the
action taken, the time the action was taken and (after an appropriate period of time) re-evaluate and document the effect of
the action taken on the patient’s problem. There should be documentation for each of the patient’s problems that are
identified. Problems should be reassessed and documented at appropriate time intervals throughout the day. Use of approved
abbreviations in your documentation is at the discretion of the instructor; otherwise write out in full sentences.
Date Time
Reviewed June 2013/JETF
NURSING CARE NOTES
CONTINUED
Date
Time
Comments:
Instructor Name (print): __________________________
Student Name (print): __________________________
_________________________
__________
_________________________
________
Instructor’s Signature
Date
Student’s Signature
Date
Reviewed June 2013/JETF
Reviewed June 2013/JETF