Your resident, Annie Harris is a 92-year-old female with a history of HTN, CHF, and late stage
dementia. She is aphasic, incontinent of her bladder and continent of her bowels. She can
ambulate and transfer with a gait belt and walker with assistance, and is a limited assist with
her bed mobility. Annie requires supervision with meals.
Document the following care provided:
0730: Cheerful, cooperative, but difficult to understand.
Partial bath
Dressing
Oral hygiene
Transfer to wheelchair
Incontinent of urine x 1 in brief
0815
Breakfast. Ate 50% of her meal and 240mL of coffee.
1130
Transfer to toilet
Incontinent of urine x 1 in brief
Small BM in toilet, soft and formed
1230
Lunch: Ate 75% of her meal and 240mL of water.
1300
Transfer to bed for nap
1400
Incontinent of urine x 1 in brief
Ambulated in hallway with gait belt and walker
Drank 120 mL of water
1500 –End of shift