1. Patient
DOB
Sex
Date
Adm. Date
Physician
Code Status
Isolation
Allergies
Diet
NPO
Fluid Restriction
Marital Status
Next of kin
Religion
Admitting Diagnosis Past Medical History Past Surgical History Meds: 08 10 12 14
Charting: 09 11 13 15
PT/OT/ST/: 08 10 12 14
IV#: TYPE: Location: IV Rate:
0700: Solution _________ Condition _____________
0900: Solution _________ Condition _____________
1100: Solution _________ Condition _____________
1300: Solution _________ Condition _____________
1500: Solution _________ Condition _____________
Vitals:
0800: T___ P ___ R ___ BP ___ Sats ____ Pain _____
1000: T___ P ___ R ___ BP ___ Sats ____ Pain _____
1200: T___ P ___ R ___ BP ___ Sats ____ Pain _____
1400: T___ P ___ R ___ BP ___ Sats ____ Pain _____
Accu-cheks:
0800______ 1200_______ 1600_____ 2000______
NEURO
LOC _____________
Orientation_________
Mental status_______
PERRLA__________
Paralysis___________
Paresthesia_________
CARDIAC
A/Pulse_______
P. Pulses______
Edema________
Cap refill______
Chest pain_____
TEDS________
RESPIRATORY
RA______________
O2 ______________
Lungs ___________
SOB_____________
Cough ___________
Trachea__________
ELIMINATION
B/Room _________
B/Pan ___________
Urinal ___________
Incontinent_______
Foley ___________
Urine____________
Stools___________
ACTIVITY
B/Rest___________
Ambulates________
Gait_____________
Walker __________
Cane ____________
Assistance________
INTEGUMENTARY
Color_____________
Warm/dry__________
Rashes____________
Turgor____________
Pressure areas______
GI
Bowel sounds__
Abdomen______
Appetite_______
Nausea________
Vomit________
Dentures______
WOUND
Incisions_________
Dressings_________
Drains___________
Staples___________
Chest tubes_______
PAIN EVAL
Onset____________
Provocation_______
Quality__________
Region__________
Severity__________
Time____________
SPECIAL
Telemetry________
Ventilator________
Enteral feed______
NG tube_________
Colostomy_______
Ileostomy________
TIME IN OUT
TOTAL
LAB VALUE
K
Na
H&H
WBC
BUN
CR
Trop
Mg
pH
Lactate
HCO3
PCO2
PREVIOUS SHIFT REPORT:
CONSULTS/ORDERS:
CXR / CT / MRI / US / heart cath. / surgery?
NOTES:
Precautions: contact / fall / seizure / aspiration / neuro√