Nurse Documentation
Digital nursing notes and charting.
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Evelyn Carter Change in condition Oct 19, 2026 9:25 AM · Day shift
Situation: Weight up 5.5 lb in two weeks, ankles swollen. Background: Heart failure, on furosemide 40 mg daily. Assessment: Mild fluid overload. Lungs with crackles at both bases. Oxygen 95% on room air. Recommendation: Called Dr. Pierce. New order to increase
Alexa Morgan, RN
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Dorothy Price Progress note Oct 18, 2026 1:40 PM · Day shift
Data: Sacral wound 3.2 x 2.4 cm, pink and red base, small drainage, no odor. Action: Cleansed with saline, foam dressing applied. Turned every 2 hours, cushion in chair. Response: Wound smaller than last week. Tolerated dressing change with pain 4 of 10.
Alexa Morgan, RN
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Harold Greene Shift note Oct 18, 2026 11:50 AM · Day shift
S: "I get winded walking to the kitchen." O: Oxygen 91% on room air at rest, 88% after walking. Breath sounds diminished at the bases. No fever. A: Breathing worse than last week. P: Physician called for an oxygen evaluation. Inhaler technique reviewed.
Marcus Hill, LPN