ALLcoyura Academy
NURSING
CLINICAL NOTES
TEMPLATE
Professional Documentation System for Student & Registered Nurses
Patient Vital Signs Head-to-Toe
Admission Log Assessment
· Demographics · 8 assessment slots · 8 body systems
· Allergies & Alerts · Critical thresholds · Findings checkboxes
· Reason for Admission · Intervention notes · Abnormality notes
Nurse's Notes Medications Care Plan
& SOAP & MAR & Goals
· Subjective & Objective · Dose & route · Nursing diagnoses
· Assessment & Plan · 5 Rights checklist · Interventions
· Narrative lines · High-alert reminders · Expected outcomes
WHAT'S INSIDE THIS TEMPLATE
Patient Profile & Demographics · Vital Signs Log · Head-to-Toe Assessment
SOAP / Narrative Notes · Medication Administration Record (MAR)
Intake & Output Chart · Care Plan · Shift Summary · Handoff (SBAR)
ALLcoyura Academy · Nursing Clinical Notes Template Page 1
,A.L.L. coyura Academy
PATIENT DEMOGRAPHICS & ADMISSION
Complete upon patient arrival — verify against armband and medical records
PATIENT IDENTIFICATION
Patient Name: Date of Birth: MRN / Patient ID:
Room / Bed: Admission Date: Attending Physician:
PATIENT DEMOGRAPHICS
Age: Gender / Sex:
Weight (kg): Height (cm):
Blood Type: Primary Language:
Religion / Cultural needs:
Emergency Contact (Name & Phone):
ALLERGIES & ADVERSE REACTIONS
■ NO KNOWN ALLERGIES (NKA) ■
If allergies exist, list below:
REASON FOR ADMISSION & DIAGNOSIS
Chief Complaint:
Primary Diagnosis:
Secondary Diagnoses:
CODE STATUS & PRECAUTIONS
Code Status: Full Code DNR DNI DNR/DNI Comfort Care Only
Isolation Precautions: Contact Droplet Airborne Reverse/Protective None
PAST MEDICAL HISTORY (PMHx)
Relevant past conditions, surgeries, hospitalisations:
ALLcoyura Academy · Nursing Clinical Notes Template Page 2
, A.L.L. coyura Academy
VITAL SIGNS LOG
Record all vital sign measurements with date, time, and nurse initials
Days (0700-1900) Nights (1900-0700)
Date: Shift: Nurse:
PARAMETER (unit) #1 #2 #3 #4 #5 #6 #7 #8
Time
HH:MM
Blood Pressure
mmHg
Heart Rate
bpm
Respiratory Rate
breaths/min
Temperature
°C / °F
SpO2
%
O2 Delivery
device / L/min
Pain Score
0–10
GCS / LOC
E+V+M / Alert
Blood Glucose
mg/dL
Urine Output
mL (last hr)
Weight
kg
Nurse Initials
CRITICAL VALUE ALERT THRESHOLDS — NOTIFY PROVIDER IMMEDIATELY
HR: < 50 or > 130 bpm BP: SBP < 90 or > 180 mmHg RR: < 10 or > 28 /min Temp: > 38.5°C or < 36.0°C
SpO2: < 90% on any O2 GCS: Drop of ≥ 2 points BG: < 70 or > 400 mg/dL UO: < 30 mL/hr for 2+ hrs
VITAL SIGNS NOTES / INTERVENTIONS
ALLcoyura Academy · Nursing Clinical Notes Template Page 3
NURSING
CLINICAL NOTES
TEMPLATE
Professional Documentation System for Student & Registered Nurses
Patient Vital Signs Head-to-Toe
Admission Log Assessment
· Demographics · 8 assessment slots · 8 body systems
· Allergies & Alerts · Critical thresholds · Findings checkboxes
· Reason for Admission · Intervention notes · Abnormality notes
Nurse's Notes Medications Care Plan
& SOAP & MAR & Goals
· Subjective & Objective · Dose & route · Nursing diagnoses
· Assessment & Plan · 5 Rights checklist · Interventions
· Narrative lines · High-alert reminders · Expected outcomes
WHAT'S INSIDE THIS TEMPLATE
Patient Profile & Demographics · Vital Signs Log · Head-to-Toe Assessment
SOAP / Narrative Notes · Medication Administration Record (MAR)
Intake & Output Chart · Care Plan · Shift Summary · Handoff (SBAR)
ALLcoyura Academy · Nursing Clinical Notes Template Page 1
,A.L.L. coyura Academy
PATIENT DEMOGRAPHICS & ADMISSION
Complete upon patient arrival — verify against armband and medical records
PATIENT IDENTIFICATION
Patient Name: Date of Birth: MRN / Patient ID:
Room / Bed: Admission Date: Attending Physician:
PATIENT DEMOGRAPHICS
Age: Gender / Sex:
Weight (kg): Height (cm):
Blood Type: Primary Language:
Religion / Cultural needs:
Emergency Contact (Name & Phone):
ALLERGIES & ADVERSE REACTIONS
■ NO KNOWN ALLERGIES (NKA) ■
If allergies exist, list below:
REASON FOR ADMISSION & DIAGNOSIS
Chief Complaint:
Primary Diagnosis:
Secondary Diagnoses:
CODE STATUS & PRECAUTIONS
Code Status: Full Code DNR DNI DNR/DNI Comfort Care Only
Isolation Precautions: Contact Droplet Airborne Reverse/Protective None
PAST MEDICAL HISTORY (PMHx)
Relevant past conditions, surgeries, hospitalisations:
ALLcoyura Academy · Nursing Clinical Notes Template Page 2
, A.L.L. coyura Academy
VITAL SIGNS LOG
Record all vital sign measurements with date, time, and nurse initials
Days (0700-1900) Nights (1900-0700)
Date: Shift: Nurse:
PARAMETER (unit) #1 #2 #3 #4 #5 #6 #7 #8
Time
HH:MM
Blood Pressure
mmHg
Heart Rate
bpm
Respiratory Rate
breaths/min
Temperature
°C / °F
SpO2
%
O2 Delivery
device / L/min
Pain Score
0–10
GCS / LOC
E+V+M / Alert
Blood Glucose
mg/dL
Urine Output
mL (last hr)
Weight
kg
Nurse Initials
CRITICAL VALUE ALERT THRESHOLDS — NOTIFY PROVIDER IMMEDIATELY
HR: < 50 or > 130 bpm BP: SBP < 90 or > 180 mmHg RR: < 10 or > 28 /min Temp: > 38.5°C or < 36.0°C
SpO2: < 90% on any O2 GCS: Drop of ≥ 2 points BG: < 70 or > 400 mg/dL UO: < 30 mL/hr for 2+ hrs
VITAL SIGNS NOTES / INTERVENTIONS
ALLcoyura Academy · Nursing Clinical Notes Template Page 3
