SAMPLE Narrative Charting Date Time Nursing Notes 5/6/13 0652 Report received from A. Smith, RN----------------------------------------------------JC,RN 0702 Assessment and vital signs completed per flow sheet; Pt reports feeling dizzy with position change; Patient instructed to call and wait for help before getting out of bed; Pt verbalizes understanding; Safety and security measures in place; Client denies other needs---------------------------------------------------------------JC, RN 0800 Meal tray delivered-----------------------------------------------------------------------JC, RN 0847 Scheduled meds given per MAR; No distress noted; client denies other needs at this time---------------------------------------------------------------------------------JC, RN 0930 Hourly rounding completed; pt denies needs-------------------------------------JC, RN 1015 Assisted pt to bathroom and back to bed; safety measures in place-------JC, RN 1105 Hourly rounding; Client reports pain in left leg; Assessment reveals redness and warmth in left calf; Pt instructed to stay in bed;----------------------------JC, RN 1108 Assessment findings reported to physician; new orders received------------JC, RN 1118 Pt to ultrasound; report to B. Brown, PCT; safety measures in place--------JC, RN 1245 Pt back to room; safety measures in place; client instructed to remain in bed; Meal tray delivered-----------------------------------------------------------------JC, RN 1250 New orders received; STAT medication given per MAR------------------------JC, RN 1320 Scheduled pain medication given per MAR; Pt pain level “4/10”------------JC, RN 1415 Pain reassessment: “1/10; I feel much better”-------------------------------------JC, RN 1455 Report to C. Jones, RN-------------------------------------------------------Joy Cole (JC), RN