PATIENT ASSESSMENT RECORDING SHEET Vital Signs

Room Intake Output Remarks

Bed Contraptions BP RR
Assigne Student/s Assigned Name of Patient IV Fluids Temp. PR SPO2
No. (NGT, IFC etc.)
d
 KARDEX

ROOM
STUDENT NAME PATIENT’S NAME AGE/SEX SUMMARY
ASSIGNED
1. Chief Complain:
Dx:
Precautions:
IV & Medications: I-
O-

2. Chief Complain:
Dx:
Precautions:
IV & Medications: I-
O-

3. Chief Complain:
Dx:
Precautions:
IV & Medications: I-
O-

4. Chief Complain:
Dx:
Precautions:
IV & Medications: I-
O-

5. Chief Complain:
Dx:
Precautions:
IV & Medications: I-
O-

Clinical Instructor: ______________________________ Area Assigned: ___________________Date & Shift: _________________

Student’s Name: ________________________ Year Level: __________ Area: _______________

Date: _________________ Shift: __________ IVF: _____________________ R: __________

Patient’s Name: ________________________ Diet/s: _______________________________

Ward/ Flr. No: __________________________ Labs: _______________________________
Room No/ Bed No.: _____________________
Vital Signs:
Diagnosis: _____________________________ T: __________ T: __________ I & O: ______
PR: _________ PR: _________ ______
______________________________________
RR: _________ RR: _________
BP: _________ BP: _________
Chief Complain: _______________________
Medications:
Precautions: ___________________________
Contraptions: __________________________
Attending Physician: ____________________

Date: _________________ Shift: __________ IVF: _____________________ R: __________

Patient’s Name: ________________________ Diet/s: _______________________________

Ward/ Flr. No: __________________________ Labs: _______________________________
Room No/ Bed No.: _____________________
Vital Signs:
Diagnosis: _____________________________ T: __________ T: __________ I & O: ______
PR: _________ PR: _________ ______
______________________________________
RR: _________ RR: _________
BP: _________ BP: _________
Chief Complain: _______________________
Medications:
Precautions: ___________________________
Contraptions: __________________________
Attending Physician: ____________________
Date: _________________ Shift: __________ IVF: _____________________ R: __________

Patient’s Name: ________________________ Diet/s: _______________________________

Ward/ Flr. No: __________________________ Labs: _______________________________
Room No/ Bed No.: _____________________
Vital Signs:
T: __________ T: __________ I & O: ______
Diagnosis: _____________________________
PR: _________ PR: _________ ______
______________________________________ RR: _________ RR: _________
BP: _________ BP: _________
Chief Complain: _______________________
Medications:
Precautions: ___________________________
Contraptions: __________________________
Attending Physician: ____________________