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