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Hi this is, (yourname) reporting in___(date) for patient
(initials) in room (.
initials) sa__(age) year old male/female patient of Doctor. (initials) who was
admitted on. (Gate) with a diagnosis of a
_____—Ginitiats) has a history of ___ (history). He/she has no
allergies/is allergicto_—-——_- His/her Code Status is,
____ (initials) underwent diagnostic tests including _____....__(imclude diagnostic
‘exams that confirm working diagnosis). (oitials) had a (surgery) and is post op
Day #____. Hishher post-op course is. (uncomplicated or complicated and include
(Gnitials) is A/O X__, ison O2 at_liters and is saturating at_%. __ initials) has
anIV on (location) and is getting (dud) at. (rate) IV site looks
good/bad (Gescribeyfhas a saline-lock____ (location).
Vital signs have been stable except pain is NO and he/she is getting for
pain which is adequate/inadequate, speech is clear, good heart sounds, strong pulses bilaterally (if applicable, if
not describe), respirations are unlabored, lungs sound clear bilaterally. Patient has bowel sounds x and
last BM was, . He/she is continent/incontinent. Is using, (BSC, urinal, bedpan)
to urinate/ has Foley catheter draining
{(deseribe fluid).
(diet) and is tolerating well.
(initials) is on strict YO ants
andhe/she got__units of insulin.
therapy (PT, OT, RT, and Dietary) is scheduled. Dr. __(initials) has also
ordered (Giagnostic test) for (Gate), include any specific mursing care for
the prep of this test.
Critical labs today are (report only critical labs or labs relevant to the admitting
diagnosis or patient history
Pt has a dressing change-to (location) orders are (Gescribe the dressing change,
site condition, REEDA assessment.
Shift priorities for you include,
Discharge Plan includes