Med Surg Report Sheet Day Shift Final PDF

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MED SURG REPORT SHEET DAY SHIFT Dx: HPI:

Name: DOB:

CODE: FULL DNR LIM_________ PMH: CAD / MI / CABG / CHF / HTN / HLD / AFIB / STENT

Allergies:

/ PE / COPD / GERD / CKD / DM / CA / TOBACCO / ETOH / ANEMIA

VITALS BP ________ HR ________ RR ________ O2 ________ T ________

INTEGUMENTARY

NEURO A&OX 1 2 3 4

BP ________ HR ________ RR ________ O2 ________ T ________

RESP RA

_____NC/HF

Baseline: _______ S/S: BiPAP

CPAP

NKDA /_______________________________

CV Rates: ______ ______ ______ ______ ______ ______

Glu

Na

Incon Foley Dialysis BM_____ t Bedp Anuria N / V / D an Retentio Urinal n BSC Bathr m Activity: PAIN

K Plt

adlib / weak bedrest assist: x1 x2 Notes

BUN

CO2

Cr

Hct

WBC

Rhythm: _________

INR

PTT

INR Hgb

Hct PT

PTT

PM / AICD

PT WBC Plt

Hg

Ca+______ Mg+______ (II)_____ Phos______ (III)_____

DIET

IV

Cl

Glu

NIH / Neuro

GI/GU

Yes

No

EF: _________ BP ________ HR ________ RR ________ O2 ________ T ________

e-

LABS

Trop (1)_____

Fluid Restriction

_______ / ____________

_________

_______ / ____________

Order:_____________________________ / NPO

_______ / ____________

Alt. Texture: _____________ BG

Notes

AC & HS

Q6

Meds: 0700 0800 0900

1000 1100 1200

Is&Os:

MED SURG REPORT SHEET DAY SHIFT 1400 1600 1800 CONSULTS: CV CTVS PULM NEURO SURG WOUND POD PALTV HOSPC

NEPH PSYCH GI ONC ID ORTHO

CAME FROM: ____________________ PLAN: HOME HH SNF REHAB...