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Report Sheet JOEY DOU
Report Sheet JOEY DOU
Date:
______________
Weight: _______lb/kg
Age: _____
Patient Name: _______________________________ Code Status: Full Code DNR Meds DNI
Allergies: __________
Isolation: ___________________ Date of Admission:
_______________________________________________
Admit Dx:
___________________________________________________________________________________
PMHx: HTN COPD CAD CHF DM CVA MI
Labs:
Neuro:
WBC:
_____ 4.5-11
A&Ox___
Eyes: ___________
Cough/Gag: _______
Restraints: ____________
Hgb: _____ 12-16 13-18
Pain Issues: ____________________ Meds Last Given: __________________
Sedation: ____________________________________
Neuro Checks Q ___hrs
Hct: _____ 36-46 37-49
Plts: _____
Na+: _____
Rhythm: ______
HR: ______ MAP: _____ Systolic: _______/Diastolic: _______
K+:
_____
Pulses: UE ___/___, LE ___/___
Edema: UE ___/___, LE ___/___
T-Max: ______ Cl-:
_____
Access: #1 ________ #2 ________ #3 ________ #4 ________ #5 ________ CVP: _____
Mg: _____
Phos _____
Resp:
Ca+: _____
Natural/#__ ETT/Shiley/Bivona
___@ Teeth/Lip
O2: RA/NC/Mask/TC/Vent/BiPAP/CPAP
i Ca+: _____
Vent Settings: ________ FiO2: _____% Rate: _____ PEEP: _____ TV: _____
BUN: _____
Breath Sounds: _______/________ Secretions: _______________ Suction Q ___
Creat:
Resp Rate: _____ SpO2: _____%
PT:
_____
Chest Tube: R/L Water Seal/Suction Drainage: ____________ OP Last Shift: _____
PTT: _____
GI:
INR: _____
CV:
100-450
135-145
3.5-5.2
95-107
1.6-2.4
2.4-4.1
8.8-10.3
2.24-2.46
7-20
_____ 0.5-1.4
10-12
30-45
1-2
HCO3:
GU:
Foley/Texas Cath/Bedpan/Urinal/Bedside Commode/Diaper
Color: __________
+/- _______mL Last Shift
Dialysis: _______________________
Skin:
#1: ________________________________________
#2: ________________________________________
.#3: ________________________________________
#4: ________________________________________
Wound Care Consulted? Yes/No
Social/Family:
0800
0900
1000
1100
1200
Drips:
________________
________________
________________
________________
________________
1300 1400
1500
_____ 19-25
To Do:
o
o
o
o
o
o
o
o
o
o
o
o
1600
Narrative: 08-10-12-1416-18
Shift re: 08 12 16
Accu
PICC:
I&O
CP:
VAP:
PT EDUCATION:
CAUTI BUNDLE:
BEDSIDE ALARMS:
SKIN BUNDLE
GCS: 8 12 - 16
1700
1800
1900