ILLINOIS CENTRAL COLLEGE PRACTICAL NURSING

DATABASE WORKSHEET

STUDENT: Age: Weight:

Patient Initials: Allergies:
Code Status:
Admitting Diagnosis

Past Medical History / Co-morbidities(H & P)/Surgical History:

Admitting Physician:
Consultations:
Treatments/Procedures/Protocols:

Misc.

Revised TP 2017
 ILLINOIS CENTRAL COLLEGE PRACTICAL NURSING
DATABASE WORKSHEET
Laboratory Results

Date Lab Test Result Acceptable Possible reason that lab is out of range
Range

Revised TP 2017
 ILLINOIS CENTRAL COLLEGE PRACTICAL NURSING
DATABASE WORKSHEET

VITAL SIGNS

Day One Time: Time:

HR: HR:
RR: RR:
T: T:
BP BP
SaO2: SaO2:
Day Two Time: Time:
HR: HR:
RR: RR:
T: T:
BP BP
SaO2: SaO2:

BLOOD GLUCOSE MONITORING

Day One Time: Time:
BGM: BGM:
INSULIN: INSULIN:
Day Two Time: Time:
BGM: BGM:
INSULIN: INSULIN:

FREQUENT MONITORING
Day One Time: Time:
Measurement: Measurement:
Time: Time:
Measurement:
Time: Time:
Measurement: Measurement:
Time: Time:
Measurement: Measurement:
Day Two Time: Time:
Measurement: Measurement:
Time: Time:
Measurement: Measurement:
Time: Time:
Measurement: Measurement:
Time: Time:
Measurement: Measurement:

Revised TP 2017
 ILLINOIS CENTRAL COLLEGE PRACTICAL NURSING
DATABASE WORKSHEET

Primary Patient Narrative Assessment Findings from Monday:

Non-Primary Patient Narrative Assessment Findings from Tuesday:

Revised TP 2017