Sample Chart Forms 2

DOCTOR’S ORDER
SURNAME: Rivera AGE: 51 years old HOSP.NO.: 00000043

GIVEN: Consuelo MI: M. SEX: Male WARD: Medical Ward
PROGRESS NOTES ORDER ACTION TIME/SIG

02/04/21 7am >oxygen therapy 2-3 L/min via nasal cannula
>IVF PNSSjL × 12⁰
>IVF D5LRSjL × 12⁰
>Diet: DAT
>Dx: 12lead ECG
Hb1AC
Trop 1
Lipid test
>Tx: Aspirin 325 mg (chewable)
Reteplase IV 10 u
Nitroglycerin IV titrate to relieve pain, holf for systolic
BP 100
Morphine 4 mg IV q5min prn for chest pain
unrelieved by nitroglycerin.
Weight-based heparin IV
Metropolol (Lopressor) 5mg IV q5min × 3 doses
>Vital SIGNs, pulse oximetry every 10 mins during infusion of
reteplase.
VITAL SIGNS GRAPHIC SHEET

Days of the Month 4 5 6 7

No. of Days in Hospital 1 2 3 4
Height/weight 5’3 / 70 kg
RESP PULSE TEMP
42
41
180 40
39
160 38
37
140 36
35
120
100
60
50 80
40
30 60
20
10
SHIFT BP U S BP U S BP U S BP U S
7-3
3-11
11-7
MEDICATION SHEET - IV

Date/Time Medication Dosage Route Freq Date 4 5 6

Ordered
Shift Time Sig Time Sig Time Sig
02-04-21 Reteplase IV 7-3
7:00 am 3-11
11-7
02-04-21 Nitroglycerin IV 10 u’ 7-3

7:00 am 3-11
11-7
02-04-21 Morphine 4 mg IV q5min prn 7-3
7:00 am 3-11
11-7
Weight-based heparin IV 7-3
02-04-21 3-11
7:00 am 11-7
Metropolol (Lopressor) 5 mg IV 7-3

02-04-21 q5min× 3 doses 3-11
7:00 am 11-7
7-3
3-11
11-7
7-3
3-11
Treatment 11-7
7-3
3-11
11-7
Breakfast
Diet Lunch DAT
Dinner
MEDICATION SHEET-ORAL
Date/Time Medication Dosage Route Freq Date

Ordered
Shift Time Sig Time Sig Time Sig
02-04-21 Aspirin 325 mg (chewable) 7-3
7:00 am 3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
O₂ inhalation @ 2-3 L/min via 7-3
nasal cannula 3-11
Treatment 11-7
7-3
3-11
11-7
Breakfast
Diet Lunch DAT
Dinner
VITAL SIGNS MONITORING SHEET

DATE/SHIFT/TIM BP PR RR CR T
E
150/70 110 28 110 37.7
02-04-21
7-3 8
12
3-11 8
12
11-7 8
12
02-05-21
7-3 8
12
3-11 8
12
11-7 8
12
02-04-21
7-3 8
12
3-11 8
12
11-7 8
12
4
NURSE’S PROGRESS NOTES

GIvEN: Consuelo MI: M. SEX: Male WARD: Medical Ward
DATE/TIME FOCUS DATA ACTION RESPONSE

2/4/21 General >received patient lying >V/S taken and >Vital signs are
recorded.
7-3 Disposition on bed. >morning care rendered. slightly elevated
>weak in appearance >bedside care done. >rapport
established.
IVF >c an IVF of PNSSjL @ >checked for patency >patent & intact.
and
1000 cc level x 12⁰. intactness. >infusing well.
>regulated to 28
gtts/min
O₂ >c an O₂ inhalation @ >checked for patency >patent & intact
and
2 LPM administered intactness.
via nasal cannula.
DIET >DAT >instructed patient to >understood &
eat nutritious foods willing to comply.
such as green leafy
vegetables because
eating a diet rich in
leafy
vegetables help to
reduce blood pressure
and improve arterial
function
Laboratory >for lipid test as ordered >explain the importance >understood
of the said procedure
exam >for Hb1AC test as >requested to lab. >endorsed
ordered
>for troponin I test as
ordered
Diagnostic >for ECG as ordered >explain the importance >understood
exam of the said procedure. >endorsed
>done
>follow-up result and
refer
Health >Health teaching >understood
Teaching imparted such as: and willing to
- the importance of comply.
taking medications
religiously such as to
improved outcomes.
-encouraged to relax
such
as do deep breathing
exercise.
- maintain bed rest
during pain wit position
of comfort to reduce
oxygen demand
2/5/21 General >received patient sitting >V/S taken and >Vital signs are
recorded.
7-3 Disposition on bed. >morning care rendered. Slightly elevated
>fair in appearance >bedside care done. >rapport
established.
IVF >c an IVF of D5LRS @ >checked for patency >patent & intact.
and
900 cc level x 12⁰. intactness. >infusing well.
>regulated to 28
gtts/min
O₂ >c an O₂ inhalation @ >Checked for patency >patent & intact
and
via nasal cannula.
such as green leafy
vegetables because
leafy
vegetables help to
function
-do relaxation comply.
techniques
such as deep breathing
exercise to promote
relaxation.
-maintain bed rest
during
pain with position of
comfort
-change positions
slowly
to minimize orthostatic
hypotension
2/6/21 General >received patient sitting >V/S taken and >V/S c in normal
recorded.
7-3 Disposition on bed. >morning care rendered. Range.
>fair in appearance >bedside care done. >RR of 27cpm
>rapport
established.
O₂ >c an O₂ inhalation @ >checked for patency >patent & intact
and
via nasal cannula.
such as green leafy
vegetables because
leafy
vegetables help to
function
-maintain healthy comply.
weight to reduce
cardiovascular risk
factors.
-avoid drinking alcohol
to prevent increase of
blood pressure because
it
is one of the most
common cause of
having
heart attack
-encouraged to do deep
breathing exercise to
promote relaxation
-encouraged rest periods
between care activities
to reduce oxygen
demand
-maintain healthy
weight to reduce
cardiovascular risk
factors
RECORD OF FLUID INTAKE AND OUTPUT

SECRE VOMITU
DATE SHIFT CLYSIS BLOOD ORAL TOTAL URINE OTHERS TOTAL
TIONS S
TOTAL
TOTAL
TOTAL
TOTAL
TOTAL
TOTAL
TOTAL
TOTAL
TOTAL
INTRAVENOUS FLUID FLOW SHEET

Type of
Cannulae
I.V. Type of Flow
Date & /Needle Date &
Fluid Nurse’s I.V. Drug Rate / Nurse’s
Time & Time Remarks
Bottle Signature Fluid & Additives Infusion Signature
Started Location Consumed
. No. Volume Device
of
Insertion
G20
G20
LABORATORY REQUEST FORM

HEMATOLOGY Total Cell Count PANCREATIC PROFILE HEPATITIS C

Complete Blood Count Differential Count Amylase Anti-HCV Screening
Hemoglobin Glucose Lipase Anti-HCV ECLIA/EIA
Hematocrit Protein LIPID PROFILE THYROID FUNCTION TEST
Platelet count LDH Total Cholesterol T3
Clotting Time CLINICAL CHEMISTRY Triglyceride T4
Bleeding Time BONE/ JOINT ARTHRITIS TEST HDL- Cholesterol FT3
Clot Retraction Time Blood Uric Acid LDL – Cholesterol FT4
ABO-Rh Typing Rheumatoid Factor LIVER FUNCTION PROFILE TSH
COAGULATION STUDIES CARDIAC MARKERS Total Protein TUMOR MARKERS
Prothrombin Time AST/SGOT Albumin AFP
APTT CK-MB Direct Bilirubin Beta-HCG
Fibrinogen Trop-T quantitative Total Bilirubin CEA
ANEMIA WORK UP Trop-I quantitative TEST FOR LIVER INJURY CA 19-9
Iron DIABETIC PROFILE AST/SGOT PSA
Total Iron Binding Capacity Fasting Blood Sugar/ FBS ALT/ SGPT CA 125
Unsaturated Iron Binding Random Blood Sugar/ RBS Alkaline Phosphatase/ALP SLE WORK-UP
Capacity
Folate OGTT _____75 g LDH Anti-Nuclear Antibody
_____100 g
Ferritin OGCT _____ 50g _____75 SEROLOGY/ IMMUNOLOGY SYPHILIS WORK UP
g
BLOOD BANKING HbA1C DENGUE WORK UP Anti T. pallidum rapid test
Direct Coomb’s test 2-HR Post-Prandial Blood Sugar DENGUE NS1 Antigen TPHA
Indirect Coob’s test Insulin Dengue IgG/IgM
DRUG TESTING Urine Ketone HIV TESTING OTHER TEST AVAILABLE
LABORATORY
Cannabinoids ELECTROLYTES Anti-HIV-1/ HIV-2 Complement3 (C3)
Screening/Rapid
Methamphetamine Sodium Anti-HIV-1/ HIV-2 EIA C-Reactive Protein
A.U.B.F./ PARASITOLOGY Potassium HEPATITIS VIRUS INFECTION Anti-streptolysin O (ASO)
MARKERS
24-h Urine HCG Titer ___Ionized/ ____Total Calcium HEPATITIS A Salmonella IgG/IgM
Pregnancy test Chloride
Routine stool examination Magnesium
Routine Urinalysis Phosphorous
TEMPLATE FOR MEDICATION CARDS
Medication card No. 1

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DOCTOR’S ORDER

SURNAME: Rivera AGE: 51 years old HOSP.NO.: 00000043

PROGRESS NOTES ORDER ACTION TIME/SIG

SURNAME: Rivera AGE: 51 years old HOSP.NO.: 00000043

Days of the Month 4 5 6 7

SURNAME: Rivera AGE: 51 years old HOSP.NO.: 00000043

Date/Time Medication Dosage Route Freq Date 4 5 6

02-04-21 Nitroglycerin IV 10 u’ 7-3

Metropolol (Lopressor) 5 mg IV 7-3

Date/Time Medication Dosage Route Freq Date

SURNAME: Rivera AGE: 51 years old HOSP.NO.: 00000043

SURNAME: Rivera AGE: 51 years old HOSP.NO.: 00000043

DATE/TIME FOCUS DATA ACTION RESPONSE

SURNAME: Rivera AGE: 51 years old HOSP.NO.: 00000043

SURNAME: Rivera AGE: 51 years old HOSP.NO.: 00000043

LABORATORY REQUEST FORM

SURNAME: Rivera AGE: 51 years old HOSP.NO.: 00000043

HEMATOLOGY Total Cell Count PANCREATIC PROFILE HEPATITIS C

TEMPLATE FOR MEDICATION CARDS

Medication card No. 1

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