Nurse Report Sheet PDF

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Summary

RN Patient report sheet. This can be used by nursing students or nurses when they are taking patient reports....

Description

NURSE REPORT SHEET Name

RM/Bed

Doctor

Age/Sex

CODE Status

Admit Date

ISOLATION ▪ None ▪ Contact ▪ Droplet ▪ Airborne

Admiting Dx

Pt History

▪ FULL CODE

Allergies

▪ DNR

Diet IV access IV fluids

Meds Timings

Mobility ▪ Independent

▪ Assist

PRN meds

▪ Bedrest

LABS

LABS

VITALS

WBC

BUN

Temp

RBC

Cr

SpO2

Hbg

Na

HR

HCT

K

RR

Platelets

Ca

BP

PT

Mg

Pain

PTT

BNP

Others

INR

Trop

Blood Sugar

Urine Output

Accu Q

Weight

▪ Alert

▪ Confused

▪ Lethargic

▪ Combative

NEUROLOGY

▪ O2

▪ Rate

▪ Clear

▪ Wheezes

▪ Speech/swallow abnormal

▪ Crackles

▪ Diminished

▪ Weakness in limbs

▪ CPAP

▪ BIPAP

▪ Restraints / Bed Alarms

▪ HHN Tx

RESPIRATORY

▪ HOH ▪ Rhythm

CARDIAC

▪ Foley

▪ Echo EF

▪ Feeding Tube

▪ Edema

▪ Fluid Restriction

GASTRO/URINARY

▪ Last BM ▪ Accu Q ▪ Intact

SKIN

▪ SCD

▪ Pressure Wound

▪ Coumadin

▪ DTI

▪ Lovenox

▪ Dressing Change

▪ Heparin

▪ Wound Consult Notes

Scheduled Procedures Scheduled Consults Discharge

▪ To Home

▪ Home Health

▪ Hospice

▪ SNF

VTE...