Sample Nurses

Notes
Ward K2
Name----------------------------------------------------------------------CHART NO
AGE---------------------------------------------SEX---------------------

DATE OF ADMISSION-----------------------------------------------WARD---------------------------CONSULTANT---------------------PROVISIONAL DIAGNOSIS-------------------------------------------------------------------------------NOTE: On admission opening statement is to include (a) mode of arrival (wheelchair, stretcher,
etc) (b) additional information not given to doctor, (c) general condition of patient and (d) any
known allergies.
28.02.2011/7am. (S) Client stated I am feeling okay. (O) Received client on unit sitting on
bench underneath tree conversing with fellow clients. He was in no observable, apparent or
discernable respiratory or painful discomfort. (A) On examination (O/E), Young, slimly built
male, aware and alert, mucous membranes, pink and moist, chest expansion
equal/even/bilateral/symmetrical and adequate (or inadequate). Skin turgor and hydration

adequate (or inadequate). No abnormalities detected to head, trunk or extremities; (however, if

abnormalities are present, you should describe them and state their anatomical position). (You
should also find out if nurses are aware of abnormalities) Vital signs at 7:05am: T98.6; P68bpm;
R16bpm; Blood Pressure 120/80mmHg.____________________________________________
______________________________________________________Horace Williams std/n NCU
(If you have another client, stop here and do the same Receival notes for him/her). If breakfast
comes before you are finished the Receival notes, allow the client to eat before you finish the rest
of the assessment, making note of the time the client ate.
Mental Status Exam (MSE)
28.02.2011/7:15am. Dress/Appearance-Client was appropriately attired for setting, age, gender
and season (you can also make reference to what the client is wearing, e.g. Client is dressed in a
white T-shirt and black shorts) with hair neatly cut/well kempt and feet shod or client was
inappropriately attired, (e.g. dressed in multiple layers of clothing) with unkempt or disheveled
hair and unshod feet. Mood/Affect (affect should reflect the mood, but they may be separated) Client stated, I am feeling okay, or clients mood appeared to be calm with congruent or
appropriate affect (if the facial expression agrees with what the client stated). For example if the
client stated that he was okay, but his face looked sad, then his affect would be incongruent or
inappropriate to his mood. On the other hand if the client stated that he felt angry, then his
face/affect should reflect that anger, if not it would be inappropriate or incongruent. If the client
stated that he is happy, but his facial expression does not show happiness or sadness it is said to
be blunted/restricted/constricted. Speech - clear, lucid, cogent/coherent, even toned and mainly
rational. (If there is little speech it is said to be poverty/paucity of speech, if the client can speak

but refuses to do so, it is called selective mutism. If the speech is a lot it is said to be
excessive/superfluous/voluminous. Listen to the tone of the speech, as well as for clarity,
coherence, cogence, lucidity, phonation, volume, quantity, is it making sense or not). Reality
orientation-Oriented to time, place or person (if the client is not oriented to one or all of the
spheres, you should orientate him and document same). Behaviour/attitude-quiet, cooperative,
focused with good eye contact and attention span, answers questions asked. (If behavior is
abnormal you document same). Thought Process: - Form - logical, lucid and connected (Note
the thought form is how the thoughts are organized) (Some abnormalities in thought form are:
Looseness of association-lack of connection in what is being said; Flight of ideas-rapid changes
in thoughts, theme or topics; Tangentiality-to go off in an oblique manner, not answering
questions asked; Circumstantiality-to supply a lot of unnecessary details before getting to the
point; Neologism-coining of new words;). Content - (this is the manifestation of the thought
form) no obsession and compulsions, no illusions, no delusions (grandiose, persecutory or
referential) suicidal or homicidal ideations, thought insertion or broadcasting detected. (If
abnormalities are present you should state them). Abstract - good, client correctly interpreted,
every cloud has a silver lining, to mean that in every difficult situation there is hope or
correctly interpreted stulla to mean a stud horse. (You dont have to use an idiomatic expression
to identify abstract ability; anything that has a hidden meaning could be used). If the abstract is
poor, you must state what was asked and the clients response. Recent Memory - Recent
memory was impaired; client could not remember what he had for breakfast this morning.
Remote Memory, this was intact, client correctly stated his date of birth.
Concentration/Attention Span - good, client could count backwards from one hundred, could
spell world backwards and could state the five items I showed him early in the interview.

Intellectual Functioning - client is able to read and write, as he read a simple paragraph and
calculated some simple equations. Insight - poor, client could not state why he was hospitalized;
he said nothing was wrong with him. Judgment - impaired, when asked what he would do if his
medication was finished, his response was, I would do nothing.____________H.W. std/n NCU
(P) Nursing Diagnosis-Risk for Ineffective Management of Therapeutic Regimen related to lack
of insight and poor judgment. (I) 1. Medicate as prescribed; 2. Decide clients education level; 3.
Ascertain what client knows about illness in relation to medication. 4. Educate on the importance
of compliance and need for continued follow up. 5. Highlight the possible side effects of
medications and ways to combat them. 6. Educate client on the disease, outcome, prognosis or
treatment regime. 7. Educate on diet and rest in relation to medication. 8. Educate on negative
interaction between medication and alcohol/substance use.H.W. Std/n NCU
28.02.2011/8am Medicated as prescribed with Cogentin 2mgs po, Chlorpromazine 100mgs po
and Tegretol 200mgs po_____________________________________________H.W. std/n NCU
28.02.2011/8:30am Tolerated breakfast_________________________________H.W. std/n NCU
28.02.2011/ 9am had one to one interaction with student nurse______________H.W. std/n NCU
28.02.2011/10am sat in group therapy session and actively participated_______H.W. std/n NCU
28.02.2011/11am played dominoes with staff and fellow clients_____________H.W. std/n NCU
28.02.2011/12-1pm Tolerated lunch___________________________________H.W. std/n NCU
28.02.2011/2pm Left on ward ambulating about, spent a satisfactory shift, nursing management
continues________________________________________________________H.W. std/n NCU

Please note: at the end of a sheet of nurses notes, it should be signed and filed in the appropriate
docket in the filing cabinet and a new one written up with the demographic information and
placed in its correction position in nurses notes folder.