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The Daily Nurses' Notes is a template for the record of the physical conditions of the patient. It includes every aspect of the body, and every item has the concrete description of the condition. At the end of the template, there is the nurse's note. This template is a general one but also a comprehensive one. If you are looking for an overall nurses' notes, this one will satisfy your need. Also, this file is free to download.

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THE VALLEY HOSPITAL
Daily Nurses’ Notes
Date:_______________
2300 – 0700 0700 – 1500 1500 - 2300
CARDIOVASCULAR
1. Heart Rate/Rhythm
2. Peripheral Pulses/Edema
3. Skin Color/Capillary Refill
RESPIRATORY
1. Breath Sounds
2. Secretions
3. 0
2
(Type)
GASTROINTESTINAL
1. Description
2. Bowel Sounds
3. Stools: Characteristics
GENITOURINARY
1. Urine: Characteristics
2. Foley
3. Discharge
NEUROLOGICAL
1. Orientation/LOC
2. Perla
3. Paresthesia/Weakness
MUSCULOSKELETAL
1. Mobility/ROM
2. Joint Swelling
HEENT
1. Inflammation
2. Discharge
3. Mucous Membranes
INTEGUMENTARY
1. Rash
2. Lesions
3. Pressure Ulcer
4. Turgor
PSYCHOSOCIAL NEEDS
1. Level of Anxiety
2. Social Interactions
PAIN (0–10) Comfort Goal___
Location, Description,
Duration, Radiation,
Provokes, Relief, Effect on
Function
pain book given
(new admit)
SIGNATURE:
Name of Agency (if applicable)
If restraints in use, follow protocol. Patient education to be documented on interdisciplinary patient/family
education form.
addressograph
NO 246 MRec Revised: 5/85; 6/86; 6/02 Page 1 of 2
Daily Nurses Notes
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