Appendix 1

Systems Approach – Documentation Guidelines


SITUATION/SUMMARY:  Start notes with a quick summary of any significant events of shift, or the reason for nursing entry (eg admission, surgery, MET call, significant clinical change or treatment).


  • Level of consciousness (Glasgow Coma Scale)
    • Alert and oriented to person, place, time
    • Delirious
    • Confusion
    • Lethargic
    • Stuporous (responds to painful stimuli?)
    • Comatose
  • Pupil assessment – size (mm), shape, reactivity, EOMs, accommodation
  • Motor movement – spontaneous, tremors, (posturing)
  • Motor strength – motor scale 0-5
    • 0/5 = no movement or evidence of muscle contraction (flaccid)
    • 1/5 = no movement; some evidence of muscle contraction
    • 2/5 = movement with gravity eliminated
    • 3/5 = movement against gravity
    • 4/5 = movement against some resistance (generalised weakness)
    • 5/5 = movement against full resistance (normal)
  • Sensory assessment
  • Coordination assessment (if indicated)
  • Cranial nerve assessment (if indicated)
  • Visual deficits
  • Auditory deficits
  • Pain assessment
  • Sedation
  • Mental state/behaviour

Ask about and record response for associated signs/symptoms – headache, seizure activity, communication problems, verbalisations, affect, memory issues/problems, aphasias, numbness, paraesthesia, change in balance.


  • Heart rate (beats/min)
  • Heart rhythm – regular/irregular.
  • Cardiac auscultation – S1 and S2 heard? Any murmurs?
  • BP (range)
  • Temperature/colour/moisture of extremities
  • Peripheral pulses (strength: 0, +1, +2, +3). Check all peripheral pulses bilaterally.
  • Capillary refill x 4 extremities
  • Oedema – generalised, dependent, pitting
  • Diaphoresis
  • ECG

Ask about and record response for associated signs/symptoms – chest pain, leg cramps, SOB, palpitations.


  • Rate, rhythm, depth, work of breathing
  • SpO2, oxygen use?
  • Accessory muscle use, breathing through pursed lips?
  • Thoracic excursion (i.e. chest expansion symmetrical?)
  • Abnormal chest shape/size
  • Tactile fremitus present?
  • Breath sounds (presence of normal or adventitious breath sounds – describe)
  • Sputum

Ask about and record response for associated signs/symptoms: orthopnoea, dyspnoea – (at rest and/or with exercise); cough (present, not present) (productive or non-productive); sputum – colour, consistency, amount, changes (increasing/ decreasing).


  • Describe as dry/warm/cool/cold
  • Colour (pallor, cyanosed, jaundiced, erythema)
  • Turgor (sluggish, brisk)
  • IV sites – type of catheter, gauge, number of lumens; location, when placed, site description, dressing (dry and intact); erythema, oedema, pain or heat at site?
  • Describe abnormalities – scars, lacerations, erythema, oedema, pain, ecchymosis, abnormal hair loss, wounds [shape, size, location, depth, colour, exudate (colour, consistency, odour, amount)].
  • Modified Waterlow Pressure Ulcer Risk score
  • Pressure area pathology described and staged
  • Hygiene requirements

Ask about and record response for associated signs/symptoms: pruritus.


  • Current diet ordered (or usual diet regulations); amount currently eating (percentage)
  • NGT/PEG – feeds or drainage
  • Fasting or nil orally
  • Dysphagia (solids, liquids, both)
  • BMI, weight (stable or recent loss/gain)
  • Bowel sounds – hyperactive, hypoactive, or present in all 4 quadrants
  • Bowel habits – changes in colour, blood present, consistency, Bristol stool chart classification
  • Abdominal palpation: masses? tenderness? guarding? soft/firm/rigid?
  • Abdominal distension (present or not), girth measurements?
  • BGL (if indicated)

Ask about and record response for associated signs/symptoms – nausea, vomiting (amount, colour, related to anything), diarrhoea, constipation, cramping, eructation, flatulence, haemorrhoids, usual frequency of stool. Describe consistency, colour. Any recent changes, any routines or aids used to maintain regularity.


  • Input for this shift/output for this shift, 24 hour intake/output, positive or negative balance?
  • IV fluid – solution, rate, additives

Ask about and record associated signs/symptoms – moist mucosa, skin turgor, thirst.


  • How is patient voiding? E.g. voiding spontaneously, with IDC, urinal, bedpan, uridome, incontinent
  • Urine – describe amount, colour, clarity, odour + urinalysis (specific gravity, urine glucose/ketones, protein, blood, bilirubin, nitrates). MSU, bladder irrigations

Ask about and record associated signs/symptoms – dysuria, nocturia, polyuria, anuria, oliguria.


  • Muscle mass, tone, symmetry of muscle size?, presence of tremor? Contractions?
  • Range of motion
  • Splints, protective devices in use (document times on/off)
  • Prostheses
  • Alignment
  • Mobility/immobility, gait
  • Falls risk assessment

Ask about and record response for associated signs/symptoms – pain, weakness, spasm, abnormalities – joint deformities, spinal deformities.


  • Family, visitors, discussions
  • Emotional or mental health considerations
  • Acute Resuscitation Plan


  • Planned procedures
  • Medical requests
  • Alterations of medication
  • Discharge planning (referrals, appointments, home support, medications)
  • Tasks yet to be completed or that need follow up


Revised TL 2015, EW 2020, EW 2022

Adapted from St Vincent’s Hospital, Melbourne. October, 2020



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Documentation in Nursing and Midwifery: Australian edition Copyright © 2022 by Tanya Langtree and Elspeth Wood is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.