BRAIN SHEET NEW SHIFT REPORT

Room:____________
DATE:____________
Patient______________________Age___Sex____ Admitted: _____HD:________LOS:_______
Diagnosis:__________________________Procedure___________________________________
Comorbid Conditions\Hx:_____________ Code Status:______Allergies____________________
______________________________________________________________________________
SIGNIFICANT HOSPITAL HISTORY

Neuro:
Orientation:

PLAN:

VARIANCE

Cardiovascular:

PLAN:

VARIANCE

Pupils:
Temp:
Weight:
Restraints

Psych/Soc

Extremity Strength
Activity
Fall Precaution:
CV:

Rhythm:
HR:
BP:
A Line
Swan Ganz:
PA
PAWP
CVP:
CO
Pacer Wires:
K+:
CPK:
CBC:
Hct:
PT
Mg+:
MBs:
Trop:
HGB
PTT
Ca:
Edema (small= +1 moderate=+2 Pitting= +3)
Pulses (R) (L) (absent=0 weak=1 strong=2)
PICC/Central line/ IJ:
Hep Lock:

DRIPS:

PUL:

BODY SYSTEMS
Neuro:

cc/hr

Extub:

BS:
Coughing
Chest Tubes:
ABG:
GI
BS
NG
Diet:
Feeding
Chemstrip:
GU
Foley:
Urine Output:

RR:

O2

Sputum
Bipap:
Mode:
FiO2
TV rate
Abd Contour
Flatus:
pH:
BM
Appetite:
Cath Care:
PD
Hemo

Skin/dressing/incisions:
Braden Scale:
Other:
Discharge Plan:

SG

Mask:
Triflow

Respiratory

PLAN:

VARIANCE

GI:

PLAN:

VARIANCE

Cuff Pressure

GU:
I&Os

PLAN:

VARIANCE

Specimens:
Test, Labs
Procedures, hx, preps
Other:
Teaching/Learning:
Consults:

Variance to Discharge Plan: Barrier

Resolution:
Consults:

Special Needs:

Ca
Mg

PTT
PT

CPK
CKMB

CKMB%
TROP