These are examples of excellent nurse’s notes that will give you context.
“When I entered the room, the patient was pale and had difficulty breathing. I called Code Blue and started CPR. The Code team showed up.
“Lung sounds clear on auscultation bilaterally. Pink color. There were no signs of respiratory distress. VSS. VSS. The patient eats 90% of meals and tolerates well. This change, there was no abdominal distension or vomiting. Patient ambulating adequately . Spontaneous emptying. In this shift, there was no BM. Patient’s weight was the same. Spouse visited the patient today. Rolls on bed up to x4. There is no danger in the room. There is a light within reach.
Nurses often refer to the computer chart when talking about charts. Many hospitals and clinics are going paperless. The physical chart (or notes) may contain only the patient’s past, while computer charts contain everything that happened during the hospital stay.