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  • MyRN Brainsheet 5pt

    Uploaded by

    Ann Williams
    41 views6 pages
    This document appears to be a patient chart or record containing assessments, vital signs, notes, and tasks for each hour over a 24 hour period. For each time interval, it includes sections for the patient's name, diagnosis, admitting physician, room, isolation status, admitting date and tech. It also includes fields for documenting vital signs, oxygen status, cardiac rate and rhythm, lung sounds, abdominal exam, bowel movements, cough, specimens, trachea status, IV access, wound care, drain status, genitourinary exams and tests, gastrointestinal information like diet, neurological status, and pain management. Labs, imaging, weight, intake and output are also included at the bottom. Medications and notes are documented separately.

    Original Description:

    RN Rounding sheet for 5 patients

    Original Title

    MyRN_Brainsheet_5pt

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    © © All Rights Reserved

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    This document appears to be a patient chart or record containing assessments, vital signs, notes, and tasks for each hour over a 24 hour period. For each time interval, it includes sections for the patient's name, diagnosis, admitting physician, room, isolation status, admitting date and tech. It also includes fields for documenting vital signs, oxygen status, cardiac rate and rhythm, lung sounds, abdominal exam, bowel movements, cough, specimens, trachea status, IV access, wound care, drain status, genitourinary exams and tests, gastrointestinal information like diet, neurological status, and pain management. Labs, imaging, weight, intake and output are also included at the bottom. Medications and notes are documented separately.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    41 views6 pages

    MyRN Brainsheet 5pt

    Uploaded by

    Ann Williams
    This document appears to be a patient chart or record containing assessments, vital signs, notes, and tasks for each hour over a 24 hour period. For each time interval, it includes sections for the patient's name, diagnosis, admitting physician, room, isolation status, admitting date and tech. It also includes fields for documenting vital signs, oxygen status, cardiac rate and rhythm, lung sounds, abdominal exam, bowel movements, cough, specimens, trachea status, IV access, wound care, drain status, genitourinary exams and tests, gastrointestinal information like diet, neurological status, and pain management. Labs, imaging, weight, intake and output are also included at the bottom. Medications and notes are documented separately.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 6

    19:00

    NAME

    FC/DNR

    DX
    MD

    Tech

    ADM DATE

    RM

    Iso

    NAME

    FC/DNR

    DX
    MD

    ADM DATE

    Tech

    Activity: A/L SBA 1 4

    ____L H

    BS

    W C GB EZ LIFT Cardio:
    Rate
    IV: P Site:__________

    Lung Sounds

    ABD
    Last BM:

    CL Site:__________
    Inf S/L Change
    VS
    Q___
    GLU Q ___H/ACHS

    Trach
    Rhythm
    Tele Eagle
    VTE
    Neuro: AAO x ___

    NPO F/R

    Cough
    Specimen
    O2 : RA NC OM BIPAP

    Activity: A/L SBA 1 5

    ____L H

    BS

    W C GB EZ LIFT Cardio:
    Rate
    IV: P Site:__________

    Lung Sounds

    ABD
    Last BM:

    Inf S/L Change


    CL Site:__________
    Inf S/L Change
    VS
    Q___
    GLU Q ___H/ACHS

    Inf S/L Change


    CL Site:__________
    Inf S/L Change

    Trach
    Rhythm
    Tele Eagle
    VTE
    Neuro: AAO x ___

    Trach
    Rhythm
    Tele Eagle
    VTE

    Cough
    Specimen

    NPO F/R

    CXR EKG CT ST

    LABS

    WT:

    I/O:

    Assessment

    Assessment

    LABS

    CXR EKG CT ST

    WT:

    ABX

    Output

    PAIN
    PCA

    ABX

    Output

    PAIN
    PCA
    GTT
    NS
    ABX

    Wound Site:

    Dressing:
    WV
    /
    DRAINS:
    GU: UTI INC HD PD
    CT: SXN WS
    Specimen
    JP OST
    BRP UR BSC BP FO

    GTT
    NS

    Wound Site:

    Dressing:
    WV
    /
    DRAINS:
    GU: UTI INC HD PD
    CT: SXN WS
    Specimen
    JP OST
    BRP UR BSC BP FO
    GI: Diet
    TF NG PT SKIN:

    GTT
    NS

    LABS

    Cough
    Specimen
    O2 : RA NC OM BIPAP

    Dressing:
    WV
    /
    DRAINS:
    GU: UTI INC HD PD
    CT: SXN WS
    Specimen
    JP OST
    BRP UR BSC BP FO
    GI: Diet
    TF NG PT SKIN:

    Inf S/L Change

    I/O:

    ABD
    Last BM:

    PCA

    LABS

    Iso

    Lung Sounds

    GTT

    ABX
    PAIN

    Output

    PAIN
    PCA

    LABS

    RM

    W C GB EZ LIFT Cardio:
    Rate
    IV: P Site:__________

    PCA

    Wound Site:

    CXR EKG CT ST

    ADM DATE

    BS

    Output

    CXR EKG CT ST

    Tech

    ____L H

    PAIN

    NS

    CXR EKG CT ST

    MD

    Output

    WT:

    DX

    Activity: A/L SBA 1 3

    NPO F/R

    ABX

    I/O:

    FC/DNR

    GU: UTI INC

    MEDS
    NS

    WT:

    NAME

    AM

    7:00

    I/O:

    Iso

    Rhythm
    Tele Eagle
    VTE
    Neuro: AAO x ___

    6:00

    Wound Site:
    Dressing:
    WV

    DRAINS:
    HD PD
    CT: SXN WS
    Specimen
    JP OST
    BRP UR BSC BP FO
    GI: Diet
    TF NG PT SKIN:

    CL Site:__________
    Inf S/L Change
    VS
    Q___
    GLU Q ___H/ACHS

    5:00

    WT:

    RM

    4:00

    I/O:

    ADM DATE

    NPO F/R

    3:00

    Wound Site:

    Cough
    Specimen
    O2 : RA NC OM BIPAP

    Inf S/L Change

    Trach

    BS
    ABD
    Last BM:

    2:00

    Assessment

    Tech

    ____L H
    Lung Sounds

    1:00

    Assessment

    MD

    Cough
    Specimen
    O2 : RA NC OM BIPAP

    0:00

    Assessment

    FC/DNR

    Trach

    23:00

    Assessment

    NAME
    DX

    NPO F/R

    Dressing:
    ABD
    WV
    Last BM:
    /
    DRAINS:
    GU: UTI INC HD PD
    CT: SXN WS
    Specimen
    JP OST
    BRP UR BSC BP FO
    GI: Diet
    TF NG PT SKIN:

    22:00

    Assessment

    Iso

    BS

    Lung Sounds

    21:00

    Assessment

    RM

    ____L H

    20:00

    Assessment

    ADM DATE

    TF NG PT SKIN:

    Assessment

    Tech

    GI: Diet

    Assessment

    MD

    W C GB EZ LIFT Cardio:
    Rate
    IV: P Site:__________
    Inf S/L Change
    Rhythm
    CL Site:__________
    Tele Eagle
    Inf S/L Change
    VTE
    VS
    Q___
    Neuro: AAO x ___
    GLU Q ___H/ACHS
    Activity: A/L SBA 1 3
    W C GB EZ LIFT Cardio:
    Rate
    IV: P Site:__________

    O2 : RA NC OM BIPAP

    Assessment

    FC/DNR

    DX

    Neuro: AAO x ___

    Assessment

    NAME

    VS
    Q___
    GLU Q ___H/ACHS
    Activity: A/L SBA 1 2

    Assessment

    Iso

    Assessment

    RM

    GTT

    NOTES

    ADM DATE

    RM
    Iso

    NAME
    DX

    FC/DNR

    MD
    Tech

    ADM DATE

    RM
    Iso

    NAME
    DX

    FC/DNR

    MD
    Tech

    LABS

    Tech

    LABS

    MD

    CXR EKG CT ST

    FC/DNR

    CXR EKG CT ST

    NAME
    DX

    WT:

    Iso

    WT:

    RM

    I/O:

    LABS

    DX

    LABS

    LABS

    CXR EKG CT ST

    Tech

    CXR EKG CT ST

    7:00

    CXR EKG CT ST

    6:00

    WT:

    5:00

    WT:

    4:00

    WT:

    3:00

    I/O:

    2:00

    I/O:

    1:00

    Assessment

    0:00

    Assessment

    Assessment

    23:00

    I/O:

    ADM DATE

    I/O:

    ADM DATE

    Tech

    22:00

    Assessment

    MD

    Assessment

    FC/DNR

    Assessment

    NAME

    21:00

    Assessment

    Iso

    20:00

    Assessment

    RM

    Assessment

    ADM DATE

    Assessment

    MD

    Assessment

    FC/DNR

    Assessment

    NAME

    Assessment

    19:00

    Assessment

    Iso

    Assessment

    RM

    AM

    DX

    MEDS
    NS

    ABX
    PAIN

    PCA
    GTT

    NS

    ABX
    PAIN
    PCA
    GTT
    NS
    ABX
    PAIN
    PCA
    GTT
    NS
    ABX
    PAIN
    PCA
    GTT
    NS
    ABX
    PAIN
    PCA
    GTT

    NOTES

    NOTES
    RM

    Iso

    VS
    Q___
    Q ___H/ACHS

    NAME

    FC/DNR

    Activity: A/L SBA 1 2

    DX
    MD

    W C GB EZ LIFT
    IV: P Site:__________
    Tech

    ADM DATE

    RM

    Iso

    NAME

    FC/DNR

    DX
    MD

    Tech

    RM

    Iso

    NAME

    FC/DNR

    DX
    Tech

    RM

    Iso

    NAME

    FC/DNR

    DX
    Tech

    RM

    Iso

    NAME

    FC/DNR

    DX

    ADM DATE

    Inf S/L Change


    CL Site:__________
    Inf S/L Change
    VS
    Q___
    GLU
    Q ___H/ACHS

    Cardio:
    Rate

    Inf S/L Change


    CL Site:__________
    Inf S/L Change
    VS
    Q___
    GLU
    Q ___H/ACHS

    Cardio:
    Rate

    CL Site:__________
    Inf S/L Change
    VS
    Q___
    GLU
    Q ___H/ACHS

    Cardio:
    Rate

    CL Site:__________
    Inf S/L Change

    TF NG PT

    SKIN:

    ____L H

    BS

    NPO F/R

    Wound Site:

    Lung Sounds

    ABD
    Last BM:

    Cough
    Specimen
    O2 : RA NC OM BIPAP

    Dressing:
    WV
    DRAINS:
    GU: UTI INC HD PD
    CT: SXN WS
    Specimen
    JP OST
    BRP UR BSC BP FO
    GI: Diet
    TF NG PT SKIN:

    ____L H

    BS

    Lung Sounds

    ABD
    Last BM:

    Cardio:
    Rate

    Cardio:
    Rate

    BS

    Lung Sounds

    ABD
    Last BM:

    NPO F/R

    Output

    Wound Site:

    Cough
    Specimen
    O2 : RA NC OM BIPAP

    Dressing:
    WV
    DRAINS:
    GU: UTI INC HD PD
    CT: SXN WS
    Specimen
    JP OST
    BRP UR BSC BP FO
    GI: Diet
    TF NG PT SKIN:

    ____L H

    BS

    Lung Sounds

    ABD
    Last BM:

    NPO F/R

    Output

    Wound Site:

    Cough
    Specimen
    O2 : RA NC OM BIPAP

    Dressing:
    WV
    DRAINS:
    GU: UTI INC HD PD
    CT: SXN WS
    Specimen
    JP OST
    BRP UR BSC BP FO
    GI: Diet
    TF NG PT SKIN:

    ____L H

    BS

    Lung Sounds

    ABD
    Last BM:

    Cough
    Specimen

    Output

    Wound Site:

    ____L H

    Trach
    Rhythm
    Tele Eagle
    VTE

    NPO F/R

    Cough
    Specimen
    O2 : RA NC OM BIPAP

    Trach
    Rhythm
    Tele Eagle
    VTE
    Neuro: AAO x ___

    Dressing:
    WV
    DRAINS:
    GU: UTI INC HD PD
    CT: SXN WS
    Specimen
    JP OST
    BRP UR BSC BP FO
    GI: Diet
    TF NG PT SKIN:

    Trach
    Rhythm
    Tele Eagle
    VTE
    Neuro: AAO x ___

    Activity: A/L SBA 1 5

    Inf S/L Change

    GI: Diet

    Trach
    Rhythm
    Tele Eagle
    VTE
    Neuro: AAO x ___

    Activity: A/L SBA 1 4

    Inf S/L Change

    O2 : RA NC OM BIPAP

    Trach
    Rhythm
    Tele Eagle
    VTE
    Neuro: AAO x ___

    Activity: A/L SBA 1 3

    W C GB EZ LIFT
    IV: P Site:__________
    Tech

    Neuro: AAO x ___

    Activity: A/L SBA 1 3

    W C GB EZ LIFT
    IV: P Site:__________

    ADM DATE

    MD

    CL Site:__________
    Inf S/L Change
    VS
    Q___
    GLU
    Q ___H/ACHS

    W C GB EZ LIFT
    IV: P Site:__________

    ADM DATE

    MD

    Inf S/L Change

    W C GB EZ LIFT
    IV: P Site:__________

    ADM DATE

    MD

    GLU

    NPO F/R

    Output

    Wound Site:

    Dressing:
    WV
    DRAINS:
    GU: UTI INC HD PD
    CT: SXN WS
    Specimen
    JP OST
    BRP UR BSC BP FO
    /

    Output

    MD

    MD

    NAME

    DX

    FC/DNR

    Tech

    ADM DATE

    RM
    Iso

    NAME

    FC/DNR

    DX

    Tech

    LABS

    Iso

    LABS

    RM

    CXR EKG CT ST

    ADM DATE

    CXR EKG CT ST

    ADM DATE

    Tech

    DX

    LABS

    DX

    LABS

    LABS

    CXR EKG CT ST

    DX

    CXR EKG CT ST

    7:00

    CXR EKG CT ST

    6:00

    WT:

    5:00

    WT:

    4:00

    I/O:

    3:00

    I/O:

    2:00

    Assessment

    1:00

    Assessment

    Assessment

    0:00

    WT:

    FC/DNR

    WT:

    NAME

    WT:

    Iso

    23:00

    I/O:

    RM

    I/O:

    ADM DATE

    I/O:

    MD
    Tech

    22:00

    Assessment

    FC/DNR

    Assessment

    NAME

    Assessment

    Iso

    21:00

    Assessment

    RM

    20:00

    Assessment

    ADM DATE

    Assessment

    MD
    Tech

    Assessment

    MD

    Assessment

    FC/DNR

    Assessment

    NAME

    Assessment

    19:00

    Assessment

    Iso

    Assessment

    RM

    AM

    MEDS
    NS
    ABX
    PAIN
    PCA
    GTT
    NS
    ABX
    PAIN
    PCA
    GTT
    NS
    ABX
    PAIN
    PCA
    GTT
    NS
    ABX
    PAIN
    PCA
    GTT
    NS
    ABX
    PAIN
    PCA
    GTT

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