Assessment Documentation Examples

Assessment                                                                 Thursday                                           Friday

General Appearance

Affect, facial expression, posture, gait

Speech

 Affect and facial expression appropriate to situation.  Patient not observed OOB. Speech clear.

Skin

Color, texture, hygiene, moisture

Braden score

Intactness, lesions, breakdown

 Skin mostly warm and dry. Braden score- 20.  Catheter insertion site found with dried sanguineous urine around meatus.  Area cleaned thoroughly.  R midline dressing covered with Telfa cloth adhesive dressing soaked with dried blood inferior to incision, gauze covering changed, JP drain intact.  Midline and 2 groin incisions at top of each leg clean, dry and well approximated with derma bond.  No other skin lesions or breakdown

Room and equipment

IV fluids, IV access

Tube feedings

Drains, Foley

 D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV.  R wrist PIV medlocked.  Foley catheter.  JP drain from R midline incision drained 19 ml sanguineous fluid, drain reactivated.  (Drain later removed by MD, incision left clean, dry and intact).

Neuro

LOC, pupils

Hand grips

Feet – flexion, extension

 Oriented x4.  Grips, flexion, extension strong bilaterally.
C-V: pulses  Heart: rhythm, S1, S2, extra sounds  Capillary refill  JVD, bruits  Edema S1, S2 auscultated over aortic, pulmonic, erb’s point, tricuspid and mitral areas.  Pulse rate 70. Radial 3+, R dorsalis pedis 2+ .  Cap refill
Resp: rate, rhythm, depth, effort  Accessory muscle use  Chest expansion  Breath sounds Rate 20, even, unlabored respirations.   No accessory muscles used.  Breath sounds clear in all areas.
GI:  abdominal shape, appearance bowel sounds x 4  tenderness  last BM, usual pattern Abdomen round and soft.  Bowel sounds x 4.Tenderness only in compromised areas.  No  BM since the day before operation (3/4/08).
G-U: voiding pattern Amount, color, clarity, Urgency, frequency, pain on voiding Bladder tenderness or distention 180 ml clear amber urine drained from Foley catheter.  No pain or bladder tenderness reported.  No distention.

Psy/ Soc

Family/ support systems

 Lives with wife, who will be caregiver as needed upon discharge

Pain

Intensity (specify tool)

Location, character

Associated signs/ symptoms

Pain interventions and effectiveness

 Pain noted at 6 on the number scale.  Pain medication administered and pain noted at 3 on same scale 30 minutes later.

Rest/ Sleep

Usual pattern/ changes since hospitalized

  Sleeping aids used

 Pt reported no sleep problems other than hospital required interruptions.
Other: specific to your patient, incl.  Dressings/ treatments

General Appearance

Affect, facial expression, posture, gait

Speech

 Flat affect.  Posture stupped. Gait unsteady and weak. Speech clear. Affect and facial expression appropriate to situation.  Posture erect. Gait weak. Speech clear.

Skin

Color, texture, hygiene, moisture

Braden score

Intactness, lesions, breakdown

 Skin pink, cool and dry. Braden score- 18.  Abdominal sagittal midline well approximated incision with packed wound at inferior and superior ends, both approx 1 cm in circumference and 11-12 mm in depth, no site redness or swelling, scant sanguiness drainage.  Three puncture wounds from laparoscopic nephrectomy, well approximated, covered with steri-strips located right medial midline, inferior and superior left lateral abdominal area, no site swelling or redness.  No other skin lesions or breakdown found. Skin pink, cool and dry. Braden score- 17.  Abdominal sagittal midline well approximated incision with packed wound at inferior and superior ends, both approx 1 cm in circumference and 11-12 mm in depth, no site redness or swelling, scant serosanguiness drainage.  Three puncture wounds from laparoscopic nephrectomy, well approximated, covered with steri-strips located right medial midline, inferior and superior left lateral abdominal area, no site swelling or redness.  No other skin lesions or breakdown found.

Room and equipment

IV fluids, IV access

Tube feedings

Drains, Foley

 NS at 50 ml/hr in 22 gauge LFA  IVAD, insertion date 6/1/08.  Dressing clean, dry, intact and reinforced with .  No other tubes, drains, or Foley. 22 gauge LFA S/L, insertion date 6/1/08. Dressing clean, dry intact, and reinforced with .  No other tubes, drains, or Foley.

Neuro

LOC, pupils

Hand grips

Feet – flexion, extension

 Oriented x4.  Grips, flexion, extension strong bilaterally. Oriented x4.  PERRL. Grips, flexion, extension strong bilaterally.
C-V: pulses  Heart: rhythm, S1, S2, extra sounds  Capillary refill

JVD, bruits

Edema

 S1, S2 auscultated over aortic, pulmonic, erb’s point, tricuspid and mitral areas.  Pulse rate 72. Radial  pulse 2+, dorsalis pedis and posterior tibial pulses 1+ bilaterally.  Cap refillS1, S2 auscultated over aortic, pulmonic, erb’s point, tricuspid and mitral areas.  Pulse rate 76. Radial  pulse 2+, dorsalis pedis and posterior tibial pulses 1+ bilaterally.  Cap refill
Resp: rate, rhythm, depth, effort  Accessory muscle use  Chest expansion

Breath sounds

 Rate 20, even, unlabored respirations.   No accessory muscles used.  RLL wet, all other breath sounds clear. Rate 20, even, unlabored respirations.   No accessory muscles used.  Breath sounds clear in all areas.
GI:  abdominal shape, appearance bowel sounds x 4  tenderness

last BM, usual pattern

 Abdomen firm and round.  Bowel sounds x 4. General abdominal tenderness reported.  Reported last BM was formed 5/31/08. Abdomen firm and round. Bowel sounds hyperactive x 4. Soft stool at approx 10:00 after administration of Ducolax suppository.
G-U: voiding pattern Amount, color, clarity, Urgency, frequency, pain on voiding

Bladder tenderness or distention

 230 ml clear, yellow urine.  No pain, urgency, frequency or tenderness with voiding reported.  No bladder distention reported. Reported voiding x 2 this morning. No pain, urgency, frequency or tenderness with voiding reported.  No bladder distention reported.

Psy/ Soc

Feelings or concerns r/t hospitalization, illness.  Recent stressors, anxiety or depression. Family/ support systems

 Pt transferred from rehab facility and expects to go back to another facility prior to going back home where wife is caregiver.  Wife has arthritis and back problems, so in-home assistance may be needed for a period of time.  Pt concerned about pet (Beauty) and not being able to take her on long walks which they both enjoy.  Not being able to do this and anticipating never being able to do this along with unrelieved pain and lack of sleep caused pt to say “if I had a gun, I would shoot myself”. Daughter (who is able to give some support for pt and caregiver) and wife are arranging placement for pt into a rehab facility upon expected discharge today.  Pt is please that he has been able to self ambulate today, but has concern of repeated evisceration.

Pain

Intensity (specify tool)

Location, character

Associated signs/ symptoms

Pain interventions and effectiveness

 Pain noted at 5 on the number scale at incision site and radiating to right side.  PRN Oxycodone pain medication administered with no relief within 30 minutes.  PRN acetaminophen administered with pain decreased to a 3 with 30 minutes.  Patients report of consistent lack of pain relief reported to his nurse. Pain noted at 5 on the number scale at incision site and radiating to right side.  PRN Oxycodone pain medication administered with pain decrease to 3 within 30 minutes.

Rest/ Sleep

Usual pattern/ changes since hospitalized

  Sleeping aids used

 Pt reported not being able to get any sleep due to unrelieved pain. Pt reported reduced pain and was able to get rest during the night.
Other: specific to your patient, incl.  Dressings/ treatments Abdominal incision site packed with NuGauze, covered with (2) 4×4, left untapped, then covered with binder. Two abdominal pads placed underneath top edge on binder to prevent chaffing.  Dressing changed by Dr. during rounds this morning.  Dressing found clean and intact with scant amount of sanguiness drainage during assessment.  Order for dressing change TID. Abdominal incision site dressed with approx. 4 inches NuGauze (both superiorly and inferiorly), covered with (2) 4×4, tapped, then covered with binder. Two abdominal pads placed underneath top edge on binder to prevent chaffing.  Dressing changed 11:00 and found scant amt of serosanguiness drainage on the both pieces of NuGauze.  Order for dressing change TID.

 

61 thoughts on “Assessment Documentation Examples”

  1. I am a new nursing student and you just helped me tons!! You would think it would be a simple thing to find someones sample notes but apparently not so much. I appreciate that you took the time to post these!
    Thanks!

  2. I have been searching everywhere online for this kind of information for my assessments and I have finally found what I need! This site has been very helpful, thank you so much!!!

  8. I have to tell you that I must have spent an hour looking for 1/2 of the information you have and found nothing. so THANK YOU. It’s awesome

  9. You should look at Tired Student Nurse. I believe she has some too. Yes, this was hard for me in school too. I received some tips from my husband (an ICU nurse). I realized I wanted to share this though, because there are no examples anywhere.

  11. I am a third year nursing student and going into the last practicum of nine weeks. this is absolutley awesome information on documentation thank you very much

  12. I’m a fresh graduate nurse this is really helpfull for me not being bully by other nurses for my charting

  16. awesome notes, i am a brand new nurse and this are the best notes i have ever seen thanks a lot.

  18. Would we have your permission to print these pages or to use them on other blogs? Thank you so much. This is a life saver.

  20. Am a new nurse and this is of great help to me. Thanks for giving permission to print coz i have to read this over and over to prepare myself for documentation once i get a job. What a relief!

  24. THANK YOU SO MUCH for posting assessment documentation examples. I’ve been looking for this type of info for a while now.

  25. It is a great help for many nurses who are looking for improving their nursing notes. Thanks a lot.
    And I am looking for a good falls assessment nursing report.

  27. I’ve been in clinicals just a couple of weeks. Tonight, I got my assessment returned and told my nursing notes “suck”. This is exactly what I’ve been looking for, and what I needed to see. Thank you so much!

  29. your sample nclex questions helped me out alot too in my nursing classes. much of the content was similar to test content. I am so glad I found your site, thank you once again for posting all of this.

  34. I’m also a very new nurse and this gave me great insite on the nursing assessment process other than what was taught to us for such short amount of time. Thanks again

  35. This is really a great site for getting info on how to do nursing documentation. It has helped me. I think is awesome. Thanks a million. I will recommended to others. God Bless.

  39. Thank you Amy, I’m a old nurse but I still need this to refresh my mind, God Bless

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  41. I am a medsurg student, doing my clinicals now. However, my client is put on a calorie count die for 3 days. Due to losing weight. Please advise, thank you.

  42. do u have any samples reguarding routine night shift notes on alcohol and drug rehab patients who are generally healthy otherwise? maybe like ensuring and maintaining a safe environment and monitoring for any signs or symptoms of withdrawal or any distress?

  43. Pingback: Sample Neurological Assessment Documentation | News Latest Update

  44. Thank you so much! It turns out there aren’t many examples on google for assessments, and this has made it 10 times easier! 😀

  47. This is a FAB post! I am also a new nurse and find it difficult to find words to write in free text because everything is pre programmed and only requires you to click boxes! Too standardized for me !

  48. Your notes are heaven sent.I being looking for that a while now finally find one which help me a lot with my care plan as a rn student at apho.thanks

  51. I am a practicing nurse and I often use this page as a guide when writing my nursing note. Nice and solid examples. Thanks.

  52. I have been looking for this kind of assessment all over online finally I found this site is very helpful to m me thanks.

  53. This is amazing, I always had doubt with my clinical assignments, but now I know what i need to do.
    Thank you very much!!!!!

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  56. I am a returning nurse out after the field for over 20 years. Excellent review. Thanks

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