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.
NAME: __________________________ DATE: __________
C.I: _____________________________
GENERAL OBJECTIVES:
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SPECIFIC OBJECTIVES:
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PLAN OF ACTIVITIES:
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SCORE: _____________
NAME: ___________________________ DATE: _______________
C.I.: _____________________________
PROGRESS NOTES:
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SCORE: ______________
NAME: __________________________ DATE: __________
C.I: _____________________________
SPECIFIC OBJECTIVES:
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PLAN OF ACTIVITIES:
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SCORE: _____________
NAME: ___________________________ DATE: _______________
C.I.: _____________________________
PROGRESS NOTES:
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SCORE: ______________
NAME: ___________________________ DATE: _______________
C.I.: _____________________________
WEEKLY EVALUATION:
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SCORE: ________
