Diagnosis: …………………… Date: …………………………

Age: ……………. Sex: …………… Date of admission: ………………..

Care status Condition Tube: …………………………

Self-care O O
Satisfactory
Partial care with assistance O Guarded O
Admission measurements
Complete care O Critical O
Exercises Diet: ………………… Height: ………………
Active exercises O Weight: ………………
Active with assistance O Blood transfusion
BP: ……………………
Types of transfusion:
Passive exercises O
Blood O TPR: …………………..
Special care
Back care O RBCs O Side rails
Platelets O
Mouth care O Constant O
Foot care O Plasma O
Perineal care O PRN O
Order date: ......................
Tracheal care O Amount: ........................... Nights O
Catheter care O Frequency: .......................
Other (Specify) O Rate: ……………………

Hospital No. : ……………………… Room No. : ………………………

Patient name: ……………………… Bed No. : ………………………...

Respiratory therapy Frequency IV devices

Oxygen O BP: …………… Type: ……………………
Liters\ minute: ………………. T: ……………..
Site: ……………………..
Method: ……………………… P: ……………..
O Size: ……………………
Nebulizer R: ……………..
Content: GCS: ……………. Date: …………………….
…………………………………
Weight: ………….
…………………………………
………………………………… Other (specify):
Methods\ Frequency: …………………..
…………………………………. ………………….
Urine output: Diagnostic studies
I & O: ……………………………….. Type Order Arrived Result
Catheter Date Date
Indwelling catheter: ……… O
……………………… …………. …………. ………….
Intermittent catheter: ……… O ………………………. …………. …………. ………….
Date inserted: ……………… ………………………. …………. …………. ………….
Size: ………………………… ………………………. …………. …………. ………….
Drain ………………………. …………. …………. ………….
Type\ No. : ………………………. ………………………. …………. …………. ………….
Location: ………………………… ………………………. …………. …………. ………….
Dressing ………………………. …………. …………. ………….
Type of wound: ………………………. …………. …………. ………….
Open O Closed O ………………………. …………. …………. ………….
………………………. …………. …………. ………….
Septic O Clean O
………………………. …………. …………. ………….
Type of solution\ Frequency: ………………………. …………. …………. ………….
………………………………….. ………………………. …………. …………. ………….
………………………. …………. …………. ………….
Special notes: ……………………………………………..
………………………………………………………….
Patient name: ………………………. Place: ………………………...
Allergies: …………………………… Diagnosis: …………………………..

Time Given
Refrigeration
Order Date

Stop Date

Drug, Dose, Route, and Frequency A.M P.M A.M Comment

6 8 10 12 2 4 6 8 10 12 2 4

St.s’ Initials: ………. Signature: ……………… Nurses’ Initials: ………. Signature: ………………