Private Duty Nursing — Clinical Notes Generator
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Timestamp:
Patient & Shift
Patient Name
DOB
MRN
Date of Shift
Shift Start
Shift End
RN Name
Co-sign (if applicable)
0700 — Start of Shift / Initial Assessment
Time
Report received from
Position
Temp (°F)
HR
RR
BP
SpO₂ (%)
FiO₂ (%)
Vent Mode
VT (mL)
RR (set)
PEEP
Pain (0–10 or FLACC)
Lung Sounds
General Comments
No signs of distress; trach midline/patent; ventilator connected and verified per order.
0800 — Medications
Time
Medications administered (dose/route)
Albuterol 2.5 mg/3 mL via inline neb; other scheduled meds per MAR
Tolerated
Yes
No
Adverse effects
0830 — Straight Cath (q6h)
Time
Catheter size
Output (mL)
Urine character
Skin/Peri-care
0900 — Respiratory Tx + Cough Assist
Time
Nebulizer
Response
1000 — PROM
Time
1100 — G-Tube Feed (q6h)
Time
Residual (mL)
Formula & Volume
Rate (mL/hr)
Flush (mL)
Tolerance
1515 — Transfer / Mobility
Time
Transfer
Vent Transition
Tolerance
1600 — G-Tube Feed (+ Protein)
Time
Residual (mL)
Formula & Volume
Rate (mL/hr)
Flush (mL)
Tolerance
1700 — Linen / Environment
Time
1800 — PROM
Time
1845 — Transfer Back to Bed
Time
1850 — Positioning & Monitoring
Time
1915 — Respiratory Tx + Cough Assist
Time
Nebulizer
Response
1945 — Tracheostomy Care
Time
Site cleansed with NS; dried; new split 4x4 applied; secretions clear/thin/odorless; no signs of infection.
1955 — Oral Care
Time
2000 — G-Tube Stoma Care
Time
Scant dried brown drainage on previous gauze; cleansed with NS; dried; new split 4x4; no erythema/swelling/odor.
2015 — Skin Care
Time
2030 — Straight Cath (q6h)
Time
Catheter size
Output (mL)
Urine character
Peri-care
2100 — Positioning & Feeding
Time
Residual (mL)
Feed
Rate (mL/hr)
Flush (mL)
Tolerance
2335 / 0400 / 0555 — Repositioning
Time 1
Time 2
Time 3
2335: Right lateral with wedges; skin intact; AFO right; heel boot left. 0400: Right lateral with wedges; skin intact. 0555: Left lateral with wedges; skin intact; AFO left; heel boot right.
2300 / 0300 — Pulse Ox Site Rotation
Time 1
Time 2
2300: Probe rotated from R index to L index; previous site intact. 0300: Probe rotated to R middle finger; skin intact.
0100 — Inventory
Time
0300 — Respiratory Treatment
Time
Nebulizer
Response
0600 — G-Tube Feed (+ Protein)
Time
Residual (mL)
Formula & Volume
Rate (mL/hr)
Flush (mL)
Tolerance
0700 — End of Shift
Time
Patient sleeping; responsive to stimuli; lungs clear; VS stable; trach patent/secure; vent functioning; safety ensured (rails, bed low/locked); no pain/distress.
Education / Safety / Other
Patient/Family education provided
Safety checks
Additional notes
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