This is a general checklist of what the unit/ ward nurse is supposed to accomplish within the EMR within the s

Directions: The system will write " YES" if DONE and "X" if NOT DONE
DAILY CHECKLIST
Date: (MM/DD/YYYY) Date:
AM PM NIGHT PRN AM PM
VS YES X
I/Os YES Yes
MAR
NCP
Monitoring
Fall Assessment
Skin Assessment
Health Teachings
Laboratory Results Checking
Health Assessment

Date: (MM/DD/YYYY) Date:

AM PM NIGHT PRN AM PM
VS
I/Os
MAR
NCP
Monitoring
Fall Assessment
Skin Assessment
Health Teachings
Laboratory Results Checking
 ithin the EMR within the shift.
OT DONE
KLIST
Date:
NIGHT PRN AM PM NIGHT PRN

Date:
NIGHT PRN AM PM NIGHT PRN
 REGISTRATION SHEET
Patient's Name: (Last Name, First Name, Middle Name)
Birthday:
Hospital Registration #:
Religion:
Address:
Date of Admission:
Chief Complaint:
Admitting Diagnosis:

Other Diagnoses:
Allergies: (Food, Meds, Scents, Particles, Others)
Reaction to Allergies:

Contact in Case of Emergency :

Name:
Address:
CellPhone # / Landline #:
PICTURE
 Nurses' Notes
Date: Time:
Notes:

Date: Time:
Notes:
Nurses' Notes
 VITAL
Date: Date: 01/31/2020
SHIFT: AM PM NIGHT PRN
TIME TAKEN: 920
BP 110/70
TEMP (Degrees Celsius) 37
TEMP ROUTE (Oral, Axillary, PR, Forehead Scan) AX
PR 98
RR 22
O2 SAT 95%
Pain Scale: 0/10
 VITAL SHEET
Date: (MM/ DD/ YY) Date: (MM/ DD/ YY) Date: (MM/ DD/ YY)
AM PM NIGHT PRN AM PM NIGHT PRN AM PM
M/ DD/ YY)
NIGHT PRN
 I
Date:
AM SHIFT
INPUT in ML OUTPUT in ML
ROUTE AMOUNT ROUTE AMOUNT
PO URINE
IVF BM
PEG TUBE DRAINAGE TUBES
JT VOMITUS
NGT
TPN
MEDS
Others Others
Total INPUT 200 Total OUTPUT 0

Others
Total OUTPUT 0
 I and O SHEET
PM SHIFT NIGHT SHIFT
INPUT in ML OUTPUT in ML INPUT in ML
ROUTE AMOUNT ROUTE AMOUNT ROUTE AMOUNT
PO URINE PO
IVF BM IVF
PEG TUBE DRAINAGE TUBES PEG TUBE
JT VOMITUS JT
NGT NGT
TPN TPN
MEDS MEDS
Others Others Others
Total INPUT 0 Total OUTPUT 0 Total INPUT 0
NIGHT SHIFT
OUTPUT in ML
ROUTE AMOUNT
URINE
BM
DRAINAGE TUBES
VOMITUS

Others
Total OUTPUT 0
Nursing Care Plan #1
Date Started: (MM, DD, YYYY) Target Date:
Cues/ Clues Nursing Diagnosis Nursing Objectives
 Nursing Care Plan #2
(MM, DD, YYYY) Date Started: (MM, DD, YYYY)
Nursing Interventions Evaluations Cues/ Clues Nursing Diagnosis
 Nursing Care Plan #3
Target Date: (MM/ DD/ YYYY) Date Started: (MM, DD, YYYY)
Nursing Objectives Nursing Interventions Evaluations Cues/ Clues Nursing Diagnosis
Target Date: (MM/ DD/ YYYY)
Nursing Objectives Nursing Interventions Evaluations
 HEALTH TEACHING
#1 Nursing Diagnosis:
Start Date:
End Date:
Health Teachings: 1)

#2 Nursing Diagnosis:
Start Date:
End Date:
Health Teachings: 1)
ALTH TEACHINGS
Directions: Change the administration box (yellow) to actions taken (see legend colors)

LEGEND: GIVEN DELAYED

NOT GIVEN DISCONTINUED
MEDICATION ADMINISTRATION
Feb. 01, 2020
MEDICATIONS TIME ADM
Cipro (ciprofloxacin) 500mg PO one tab every 12 hrs for 10 days 1000
Start Date : Jan. 31, 2020 End Date: Feb. 10, 2020 2200

Multivitamin one tab PO daily 1200

Start Date: Feb. 01,2020 End Date: NONE

Losargard (losartan) 50mg PO every bedtime 2100

Start Date: Feb. 01, 2020 End Date: May 31, 2020
MINISTRATION RECORD (MAR)
Feb. 02, 2020 Feb. 03, 2020
TIME ADM TIME ADM
1000 1000
2200 2200

1200 1200

2100 2100
Date: 02/01/220
Blood Exam Test: CBC with differential count
Date: 01/31/2020
Procedure: Chest Xray

Results: Normal Chest Xray

MD NAME & ID: Dr. Farokh Contractor ID # 4321

Date: 02/01/2020
Procedure: MRI ABD
Results :MRI scan of the pelvis demonstrating the fibrous dysplasia of the right proximal femur with th
MD Name & ID #: Dr. Jose Santos ID # 1254
Date: 01/31/2020
Procedure: CT of ABD

Results: Normal findings

MD NAME & ID: Dr. Farokh Contractor ID # 4321
right proximal femur with the femoral neck fracture
 Doctor's Progress No
Date: Time:
Notes:

Date: Time:
Notes:
Doctor's Progress Notes