BUKIDNON STATE UNIVERSITY

COLLEGE OF NURSING
MALAYBALAY CITY

Patient Monitoring Sheet

Patient: ___________________________________________________ Age: _____ Sex: ______ Date: ___________
Diagnosis: _________________________________________________ Diet: __________________________________

SPECIAL ENDORSEMENT DATE SAMPLE CHARTING

INTAKE AND OUTPUT

Shift Oral IVF Total Urine Other Total

IV FLUID/ BLOOD LINE / SIDE DRIP

Bottle No. /Name / Volume / Rate Level

VITAL SIGNS MONITORING

DATE TIME T P R BP FHT

NAME OF DRUG Timing

Example: Mefenamic Acid 500mg tab PO od bid tid qid q4 q6 q8 q12 prn stat

STUDENT NURSE: _______________________________ CLINICAL INSTRUCTOR: ___________________________________

NOTE: Please submit this form together with your PONR. One form per day!
Use lead pencil for sample charting.