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 CHECKLIS
Date: (April 29, 2021)
AM PM
VS (BP) 120/80 mmHg
Temp. 36.5
Pulse Rate 67
Respiratory Rate 22
I/Os (Intake) 1500 cc
(Output) 1400 cc

MAR
Cefuroxime 1g q12' IV 3pm
Mefenamic Acid 500mg, PO, q8' 1pm

NCP
Monitoring
Fall Assessment High Risk
Skin Assessment
Health Teachings
Laboratory Results Checking Referred
Health Assessment
plish within the EMR within the shift.
nd "X" if NOT DONE
DAILY CHECKLIST
Date: Date:
NIGHT AM PM NIGHT PRN AM PM NIGHT PRN
 REGISTRATION SHEET
Patient's Name: (Last Name, First Name, Middle Name) Owens, Martin L
Birthday: March 19, 2001
Hospital Registration #:
Religion: Christian
Address: Colorado USA
Date of Admission: 04/29/2021
Chief Complaint: Right sided hip/Lower Back Pain of 18 mont
Admitting Diagnosis: Slipped Capital Femoral Epiphysis

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

Contact in Case of Emergency :

Name: Owens, Linda L
Address: Colorado USA
CellPhone # / Landline #: 0929301793
 PICTURE

wer Back Pain of 18 months duration

moral Epiphysis
 NURSING CARE PLAN
FOCUS DATA/ACTION/RESPONSE
D-

A-

R-
RESPONSE
Name:
Date Admitted:
Address:
Attending Physician:

IVF MONITORING SHEET

DATE IVF INCORPORATION
April 29, 2021 D5LRS 1L X 8 hrs Vitamin B Complex 2amps
IVF MONITORING SHEET
TIME STARTED FLOW RATE AMOUNT INFUSED AMOUNT ENDORSED
9:40am 30 gtts/min 750cc 250cc
Date: Date: 01/31/2020
SHIFT: 8-Apr
TIME TAKEN: 8am 9am 10am
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)
Date:
AM SHIFT
INPUT in ML OUTPUT in ML
ROUTE AMOUNT ROUTE AMOUNT
PO 750 cc URINE 1100 cc
IVF 750 cc BM 1x
PEG TUBE N/A DRAINAGE TUBES N/a
JT N/A VOMITUS None
NGT 50cc
TPN N/A
MEDS 10cc
Others Others
Total INPUT 1560 cc Total OUTPUT

Others
Total OUTPUT 0
 I and O SHEET
PM SHIFT NIGHT SH
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
1100cc Total INPUT 0 Total OUTPUT 0 Total INPUT
NIGHT SHIFT
OUTPUT in ML
ROUTE AMOUNT
URINE
BM
DRAINAGE TUBES
VOMITUS

Others
0 Total OUTPUT 0
Nursing Care Plan #1
Date Started: (MM, DD, YYYY) Target Date:
ASSESSMENT Nursing Diagnosis PLANNING
 Nursing Care Plan #2
(MM, DD, YYYY) Date Started:
Nursing Interventions Evaluations ASSESSMENT
Plan #2
(MM, DD, YYYY) Target Date: (MM/ DD/ YYYY)
Nursing Diagnosis PLANNING Nursing Interventions Evaluations
Nursing Care Plan #3
Date Started: (MM, DD, YYYY) Target Date: (MM/ DD/ YYYY)
ASSESSMENT Nursing Diagnosis PLANNING 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 ADMINISTRATIO
April 28, 2021
MEDICATIONS TIME
Cipro (ciprofloxacin) 500mg PO one tab every 12 hrs for 10 days 8am
8pm
Start Date : Jan. 31, 2020 End Date: Feb. 10, 2020

Multivitamin one tab PO daily

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

Losargard (losartan) 50mg PO every bedtime

Start Date: Feb. 01, 2020 End Date: May 31, 2020
ON ADMINISTRATION RECORD (MAR)
April 28, 2021
ADM TIME ADM TIME ADM
DISCONTINUED
asleep (APRIL 29 2021 10AM)
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 t
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
ight proximal femur with the femoral neck fracture
 Doctor's Progress N
Date: Time:
Notes:

Date: Time:
Notes:
Doctor's Progress Notes