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Skilled Nursing Charting Template

SKILLED NURSING CHARTING RECORD Neuro # Alert # Confused # Lethargic # Sedated # Agitated # Non-responsive Oriented: # Person # Place # Time Speech: # Clear # Slurred # Aphasia Respiratory 1. Rhythm: # Regular # Irregular # Short of breath on exertion Oxygen: # None # __ l / m # No Cough # Non-productive # productive breath Sounds:

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3K views1 page

Skilled Nursing Charting Template

SKILLED NURSING CHARTING RECORD Neuro # Alert # Confused # Lethargic # Sedated # Agitated # Non-responsive Oriented: # Person # Place # Time Speech: # Clear # Slurred # Aphasia Respiratory 1. Rhythm: # Regular # Irregular # Short of breath on exertion Oxygen: # None # __ l / m # No Cough # Non-productive # productive breath Sounds:

Uploaded by

berhanubedassa
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • GU
  • Safety
  • Musculoskeletal
  • Vital Signs
  • Respiratory
  • Cardiac
  • Voiding
  • GI
  • Neuro

SKILLED NURSING CHARTING RECORD SHIFT D / E / N

Neuro □ Alert □ Confused □ Lethargic □ Sedated □ Agitated □ Non-responsive


Oriented: □ Person □ Place □ Time Speech: □ Clear □ Slurred □ Aphasia

Respiratory Rhythm: □ Regular □ Irregular □ Short of breath □ Short of breath on exertion


Oxygen: □ None □ __ l/m □ No Cough □ Non-productive □ Productive
Breath Sounds: RUL __ RML __ RLL __ LLL __ LUL __
1. Clear 2. Crackles 3. Wheezes 4. Diminished 5. Rhonchi

Cardiac
Rhythm: □ Regular □ Irregular
Radial: RT □ Present □ Absent LT □ Present □ Absent
Pedal: Rt □ Present □ Absent LT □ Present □ Absent
Edema: □ None □ Present (□ 1+ □ 2+ □ 3+ □ 4+) Location: _______________

GU Abdomen: □ Soft □ Firm □ Rounded □ Distended □Tender / Location: ________


Bowel Sounds: □ Present □ Absent X___Quadrants C/O □ Nausea □ Vomiting □ Diarrhea

Musculoskeletal
Mobility: □ Full □ Limitations Describe: ____________________________________________
Gait: □ Steady □ Unsteady Activity: □ Self □Assist □ Total
HOB: □ Up _____ Deg. ROM: □ Self □ Assist

Skin
Color: □ Normal □ Cyanotic □ Pale Condition: □ Dry □ Moist
Temperature: □ Cool □ Warm Integrity: □ Intact □ Not intact
Skin Integrity Protocol: □ Yes □ No □Turned approximately every 2 hours □Turns Self

Psych
Affect: □ Calm □ Anxious □ Flat □ Confused □ Depressed □ Combative □ See Behavior documentation MAR
Communication: □ Intact □ Impaired
Involvement with plan of care: □ Active □ Refuses □ Dependent

Pain □ Denies □ Location __________ Intensity (Scale 0-10) _________


Pain Medication: □ Effective □ Non Effective (If ineffective, document in nurses notes)

Nutrition
Appetite: Good / Fair / Poor

Safety
Siderails: □ Full □ Half Transfers: □ Use lift □ 1 asst □ Total □ Independent
Fall Risk Protocol: □ Yes □ No □ Call light in reach □ Low Bed □ Restraint

Voiding Color: □ Yellow □ Amber □ Blooding □ Other _________


Appearance: □ Clear □ Cloudy □ Sediment □ Odor □ Dysuria □ Frequency
Catheter: □ Foley _____ □ Straight ___ □ See Intake and Output

VITAL SIGNS: B/P _________ PULSE _______ RESP ______ TEMP _____

DOCUMENT ANY ISSUES REQUIRING FURTHER EXPLANATION ON NURSES NOTES


Medical Record No. Room/Bed Date Licensed Nurse’s Signature

Patient Name Physician

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