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: 7:30am Received (lying on bed/from admitting section per stretcher/per arm) (asleep/awake); conscious; coherent; responsive to any kind of stimuli; not in respiratory distress. (3pm) With pupils equally round and (briskly/sluggishly) reactive to light stimulation; with pupil size of _____mm. (11pm) With O2 inhalation at ____LPM via (face mask/nasal cannula/prong) With NGT Fr.__ at (left/right) nares; patent and intact; distal end closed for feeding and medication. With (endotracheal/tracheostomy) attached to mechanical ventilator with the following set up: With symmetrical lung expansion With (clear breath sounds/crackles/wheezes) on both lung fields noted upon auscultation. With IVF of (PNSS/D5LR/D5NSS)@_____cc/hr infusing well @ _____vein @ ______cc level With side drip of ______@_______cc/hr @ ______cc level With Foley catheter attached to urobag draining to a _______colored urine With (pinkish/pale/cyanotic) nail beds noted with capillary refill of ____seconds With (good/poor/senile) skin turgor On (diet as tolerated/small frequent feedings/hypoallergenic diet/diabetic diet with calculations) On moderate high back rest (or maintained on moderate high back rest) On complete bed rest (with/without) bathroom privileges For (urinalysis/fecalysis/sputum AFB) not yet saved; instructed; provided with container. *(saved; specimen sent to lab) For (CBC/FBS/ligid profile/serum creatinine/SUA) (encoded/with ok/slip still with watcher).*(extracted) For (2D echo/chest x-ray); (encoded/with ok/slip still with watcher) *(done) For (ultrasound of liver, gallbladder/CT scan of whole abdomen); (instructed/maintained) on NPO. *(done) *note: To 2D echo dept. /X-ray dept/Heart station/Ultrasound dept) *per (stretcher/wheelchair) Transported back to room per (stretcher/wheelchair). ______________ procedure done. To secure ______ units (PRBC, platelet concentrate) type____and transfuse after proper cross matching ;( still securing/with available at lab) 8:00am Initial VS checked and recorded; (afebrile/febrile) *if febrile, temp=______ºC (4pm) *note: indicate all unusualities: NOD aware; referred to Dr.________ (12mn) *note: document your interventions (e.g.: if febrile (TSB done/Paracetamol 500mg 1tab PO given as ordered) *note: document all PRN meds/stat meds given) NVS checked and recorded; RLS of __; GCS of ____; oriented; with spontaneous eye opening; obeying to commands; with (strong/weak/absent) motor response on both and lower extremities. Bedside care done; linens (changed/stretched); tucked well. Placed the patient comfortably on bed Oral care done 9:00am Osteorized feeding of _____cc given; flushed with _____cc of water; well tolerated. (5pm/1am) Seen and examined by Dr._________; with orders made; *note: document the orders especially diagnostic exams and procedures; carried out by NOD 11:00amHGT taken; with result of ____mg/dl; NOD aware. Referred to Dr._________ (7pm/3am) 11:30amMeal served; able to consume __________ of the meal 12:00nn VS rechecked and recorded; (afebrile/febrile) (8pm/4am) 1:00pm Above IVF consumed and followed up with ________@_______cc/hr. Above IVF consumed and terminated. (9pm) Assisted the patient in the comfort room; voided freely (5am) Health teachings rendered such as: a) Instructed patient to have adequate rest and sleep; b) Instructed to perform deep breathing and coughing exercises; c) Instructed to eat foods rich in ___________; d) Instructed patient to avoid foods rich in ____________; e) Instructed watcher to turn patient to sides every 2-3 hours; f) Instructed watcher to assist patient in performing ADL g) Encouraged to comply with treatment regimen. *note: health teachings should be based on patient’s health condition and must be congruent with the medical order. 2:30pm Intake and output summed up and recorded. (10:30pm) Watched for unusualities such as________________; not noted/noted (6:30am) Due PO meds given Due IVTT meds given by NOD Turned to sides every 2 hours, and back massage rendered. Suctioned secretions as necessary Left on bed (resting/asleep) with same IVF on; with watcher @ bedside *note: for discharge 3:00pm Endorsed to NOD (11pm) *note: Health teachings rendered such as: (discharge plan) (7am) Home meds instructed Discharge per (wheelchair/stretcher) with accounting clearance.
___________________St.N. Signature over printed name