(FOR LEARNING PURPOSES ONLY)

UNATHORIZED REPRODUCTION IS PUNISHABLE

BY LAW. BY: NEUST

Student’s Name: Datu, Beverly Jane L. Date: 09/03/2020 BSN2HGRPS1&2

SAMPLE VITAL SIGNS RECORD FORM

Name: ____Patient 1________ Room No. : ______ Bed: _______ Ward: _ Hospital No: ___________

DATE 2-04-2021 2-05-2021 2-06-2021 2-07-2021 2-09-2021

Hospital Days 1 2 3 4 5
Post-Operative Days
Ink
Pulse – Red Ink

Pulse Temp AM PM AM PM AM PM AM PM AM PM
o 4 8 1 1 2 2 4 8 1 1 2 2 4 8 1 1 2 2 4 8 1 1 2 2 4 8 1 1 2 24
C 2 6 0 4 2 6 0 4 2 6 0 4 2 6 0 4 2 6 0
Blue

41
170

160

150 40

140

130 39

120

110 38

100

90 37

80

70 36

60

50 35
3
Respiration 2
c
p
m
Blood Pressure
Height 6-2 2-10 10-6 6-2 2-10 10-6 6-2 2-10 10-6 6-2 2-10 10-6 6-2 2-10 10-6
Weight
Urine
Stool
(FOR LEARNING PURPOSES ONLY)
UNATHORIZED REPRODUCTION IS PUNISHABLE
BY LAW. BY: NEUST