NURSES NOTES

LAST NAME FIRST NAME MIDDLE NAME ROOM BED # HOSP

# #
DATE/TIME FOCUS PROGRESS NOTES
2/24/17 0730H Promotion of Safety and D: -Received patient awake and

Comfort coherent in sitting position

-Afebrile (35.4); Not in distress

A: -Established rapport with patient

-Vital Signs Taken and recorded

-Ensure safety of patient: side rails

up and instructing to move in a much

safe position

-Encouraged verbalization of

concerns

-Concerns reported to nurse on duty

-Administered medications

-Continuous monitor bowel

movement

R: -Patient was stable and able to

respond to interventions

Vincent C. Bulla