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ICU Nurse Report Sheet Template

This document contains fields for recording a patient's admission information including their name, age, vital signs, admission date and reason, current medical problems, allergies, activity level, diet, neurological exam, skin exam, and notes for recent procedures, labs, intake and output, medications, and re-evaluation. It provides a way to document the essential details of a patient's admission on one page.

Uploaded by

HayleyLangley
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
15K views1 page

ICU Nurse Report Sheet Template

This document contains fields for recording a patient's admission information including their name, age, vital signs, admission date and reason, current medical problems, allergies, activity level, diet, neurological exam, skin exam, and notes for recent procedures, labs, intake and output, medications, and re-evaluation. It provides a way to document the essential details of a patient's admission on one page.

Uploaded by

HayleyLangley
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Room#

Pt Initials:
POA:
Code:

M / F
Age:
HT:
WT:

Pref. name:
Isolation:

Family/Contact Info:

Accucheck: Y / N
Restraints: Y / N

Admit Date:

Admit Reason(s):
Current Problems:

Allergies:

Activity:

Vitals:
HR:
BP:
RR:
Temp:
Shift:
SPO2:
PIV / CVC / PICC #1
R / L site:
Fluid/Rate:

RN:
Instructor #:
1

Diet:
Neuro:
Resp:

PIV / CVC / PICC #2


R / L site:
Fluid/Rate:

PIV / CVC / PICC #3


R / L site:
Fluid/Rate:

GI:
GU:

Cardiac:

Tele/Pack#

Void Status:
Last BM:
Medical History:

Skin:

M/S:
Pain:

RUE:
LUE:
Other Notes:

RE-EVAL

Recent Procedures:

RLE:
LLE:

#
2

Labs:
K:
Mg:
Na:
Ca:
Troponin:
BNP:
EF:
PT:
INR:
ALT/AST:
Hgb:
Hct:
RBC:
WBC:
Albumin:
Platelet:
Cr:
BUN:
GFR:
PO2:
PCO2:
HCO3:
pH:
Chol:
Lipid:
LDL:
HDL:

I/O Notes:

Meds:
______ __

________ _

_______ _

________

________

___ ____

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