Shift documentation example:
730: report received from primary RN. -----DB
800: pt is aaox3. assessment complete. VSS. 97.1 94 20 117/54 98%RA. Mucous membranes
are pink, moist, and intact. No facial droop or tongue deviation noted. Lungs are clear to
auscultation anteriorly and have crackles to bilateral bases. Heart tones are irregular and monitor
shows afib in the 90s. apical pulse is 98 and irregular. Abd is soft, round, and non-tender with
bowel tones normoactive x 4 quadrants. Radial pulses are strong, irregular, and palpable. Pedal
pulses are weak bilaterally. Pt denies pain at this time. No facial grimacing or guarding noted.
Homan’s sign is negative bilaterally. 2+ pedal edema noted and it extends to the knees
bilaterally. IV site is CDI with NS 0.9% infusing without difficulty at TKO 10ml/hr. Will
continue to monitor. ---DB
900: bed bath complete. Linens changed. Skin is warm and dry. No breakdown noted. Assist
patient x 1 to chair with gait belt and walker. Will monitor. Afib 90s-110s.---DB
1000: Assist patient back to bed x 1 with gait belt and walker. Pt denies pain at this time. Will
continue to monitor. Afib 90s-110s.—DJB
1040: pt rests with eyes closed. Will monitor.—DB
1145: VSS 98.1 85 16 125/74 94%RA. One Touch= 110. Primary RN notified. Assist patient x
1 to chair with gait belt and walker. Awaits lunch. Assessment Complete. No change since
previous assessment. Will continue to monitor. Afib 105-115.—DB
1230: Eats 100% meal. Ambulates hall approximately 100 ft with 1 to assist using gait belt and
walker. Tolerates activity well. Returns to bed after ambulation complete. Afib 110-120. Will
monitor—DB
1240: assist pt x1 return to chair using gait belt and walker. Denies pain at this time. Afib 100s.
–DB
1300: Report off to primary RN—DB
(VSS= vital signs stable)
(TKO= to keep open)
(CDI=clean, dry, and intact)
(RA= room air)
(AAO= Awake, Alert and Oriented)