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

Directions: The system will write " YES" if DONE and "X" if NOT DONE

Date: (MM/DD/YYYY)
AM PM NIGHT
VS YES YES
I/Os
MAR YES
NCP YES
Monitoring YES
Q Shift Head to Toe Assessment
Fall Assessment X
Skin Assessment YES
Health Teachings
Laboratory Results Checking
Discharge Planning
ABD Girth
Weight

Date: (MM/DD/YYYY)
AM PM NIGHT
VS
I/Os
MAR
NCP
Monitoring
Q SHIFT Head to Toe Assessment
Fall Assessment
Skin Assessment
Health Teachings
Laboratory Results Checking

YES
X
plish within the EMR within the shift.
"X" if NOT DONE
DAILY CHECKLIST
Date:(MM/DD/YYYY) Date:(MM/DD/YYYY)
PRN AM PM NIGHT PRN AM

Date: Date:
PRN AM PM NIGHT PRN AM
MM/DD/YYYY)
PM NIGHT PRN

PM NIGHT PRN
Head to toe Assessment
Assessment conducted by ___________
Alert Person
Drowsy Place
Lethargic Time
Stupurous Situation
Coma
 REGISTRATION SHEET
Patient's Name: (Last Name, First Name, Middle Name)
Gender:
Birthday:
Hospital Registration #:
Religion:
Address:
Date of Admission:
Chief Complaint:
Admitting Diagnosis:

Other Diagnoses:

Height / Body Weight/ BMI

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

Contact in Case of Emergency :

Name:
Address:
CellPhone # / Landline #:
Release of Information Signed : Yes/NO
Advance Directive/ Type:
Code Status:

Yes
No
 Picture
EGISTRATION SHEET
PICTURE
Date: Date: (02/25/2020)
SHIFT: 0400h
TIME TAKEN: 0405h
BP 110/60
TEMP (Degrees Celsius) 36.8
TEMP ROUTE (Oral, Axillary, PR, Forehead Scan) Axillary
PR 98
RR
O2 SAT 98%
Pain Scale: 0
Pain Scale Used: Facial Grimace
 VITAL SH
(02/25/2020)
0800h 1200h 1600h 2000h 0000h PRN
0800h 1205h 1600h 2000h 0000h
 VITAL SHEET
Date: (MM/ DD/ YY) Date: (MM/ DD/ YY)
AM PM NIGHT PRN AM PM
920 920
110/70 110/70
37 37
AX AX
98 98
22 22
95% 95%
0/10 0/10
 Date: (MM/ DD/ YY)
NIGHT PRN AM PM NIGHT PRN
920 920 920 920 920 920
110/70 110/70 110/70 110/70 110/70 110/70
37 37 37 37 37 37
AX AX AX AX AX AX
98 98 98 98 98 98
22 22 22 22 22 22
95% 95% 95% 95% 95% 95%
0/10 0/10 0/10 0/10 0/10 0/10
 Bowel Sound
Monit
AM SHIFT PM SHIFT NIGHT SHIFT
Date/ Time 3 BS/min Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
 Monitoring
NIGHT SHIFT AM SHIFT PM SHIFT NIGHT SHIFT
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
Date/ Time Date/ Time Date/ Time
NIGHT SHIFT
Date/Time:
Notes:

Date/Time:
Notes:
Nurses' Notes
Date:
AM SHIFT
INPUT in ML OUTPUT in ML
ROUTE AMOUNT ROUTE AMOUNT
PO 100 URINE 300
IVF 450 BM 0
PEG TUBE DRAINAGE TUBES
JT VOMITUS
NGT
TPN
MEDS 30
Others Others
Total INPUT 580 Total OUTPUT

Others
Total OUTPUT 0
 I and O SHEET
PM 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
300 Total INPUT 0 Total OUTPUT
 NIGHT 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
0 Total INPUT 0 Total OUTPUT
0
 NURSING CAREPLA
Nursing Care Plan #1
Date Started: (MM, DD, YYYY) Target Date: (MM, DD, YYYY)
Cues/ Clues Nursing DiagnosisNursing ObjectiveNursing InterventEvaluations
Administer Paracetamol 500mg PO every 6hrs PRN for fever
DAT
Weigh daily
SING CAREPLAN
Nursing Care Plan #2
Date Started: (MM, DD, YYYY) Target Date: (MM/ DD/ YYYY)
Cues/ Clues Nursing DiagnosisNursing ObjectiveNursing InterventEvaluations
6hrs PRN for fever
Nursing Care Plan #3
Date Started: (MM, DD, YYYY) Target Date: (MM/ DD/ YYYY)
Cues/ Clues Nursing DiagnosisNursing ObjectiveNursing InterventEvaluations
 H
#1 Nursing Diagnosis:
Start Date:
End Date:
Health Teachings: 1)

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

LEGEND: GIVEN DELAYED

NOT GIVEN DISCONTINUED

MEDICATIONS
Lactulose 5 ml PO daily
Start Date : February 25, 2020
end colors)

MEDICATION ADMINISTRATION RECORD (MAR)

Feb. 01, 2020 Feb. 02, 2020 Feb. 03, 2020
TIME ADM TIME ADM TIME

8:00
MAR)
Feb. 03, 2020
ADM
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 the fem
MD Name & ID #: Dr. Jose Santos ID # 1254
Abdominal X Ray
February 25, 2020
Date: 01/31/2020
Procedure: CT of ABD

Results: Normal findings

MD NAME & ID: Dr. Farokh Contractor ID # 4321
roximal femur with the femoral neck fracture