RM: NAME: AGE:

F|M ACP: R M C DAILY ASSESSMENT/CARE

VITAL SIGNS
ISO: MD: Teaching | Non-Teaching TIME BP MAP HR RR O2 Therapy TEMP

ADMITTED: LOS: ELOS: EDD:

PAST MEDICAL HISTORY: ALLERGIES:

H2T ASSESSMENT
NEURO: LOC: (Alert / Drowsy / Lethargic) Orientated x _____ (person / place / time)
ADMITTING DIAGNOSIS:
Behaviour (appropriate / cooperative / non-compliant / combative / aggressive)
HPI:
Dizziness ______ Headache _____ Syncope ______ Weakness ______
Numbness / Tingling ______ Facial Droop _______ Strength ________
CVS: Chest Pain: Y | N Location: ______________ Severity: _______ Radiating: ____________
Pulses: Radial ___ | Pedal ___ (absent – 0, weak – 1+, N – 2+, bounding 3+)

DIAGNOSTICS: Edema:
Weights *Telemetry? Y | N (rhythm: ________)
IV SITES: Heparin IV rate: @ ______u/hr
*ACS Protocol / DVT Protocol aPTT Due @ _____
IVF:
ENDOCRINE: (QID / TID / BID / OD) Accuchecks
PERTINENT LAB VALUES: BLOOD WORK TODAY? Y | N *Diab. Meds:

RESP: Airway (patent / at risk / not patent) Air Entry: __________________________________

Lung Sounds: (Clear / Decreased / Wheezes / Crackles / Rhonchi / Other ____________)
IVS/TUBES/DRAINS/DRSGS:
SOB: _______ WOB: (Nasal Flaring / Pursed Lips / Accessory Muscles / Clipped Speech)
Cough: (none / wet / dry / chronic) Sputum (colour/amt):
Chest Tubes: CPAP/BIPAP:

GI: Abd: (soft / firm / distended / non-tender / tender / guarding / large)

CONSULTATIONS/RECOMMENDATIONS: BS x _______ LBM: ________ (soft / formed / loose / diarrhea / blood / black stool)
Ostomy: N&V: *Anti-emetic given:
NG Tube / TF:
GU: VOIDS (qS / oliguic / anuric ) FOLEY: OUTPUT:
DISCHARGE PLANNING: Clear / Cloudy / Yellow / Amber / Dark / Hematuria Dysuria: 5
Bathroom / Commode / Urinal / Bedpan / Incontinent INS&OUTS 5
SKIN: MSK:
LIVING SITUATION:
Colour: (Pink / Pale / Mottled / Cyanotic)
DIET: MOBILITY: TOILETING:
Temperature: (Hot / Warm / Cool / Cold)
SPECIAL CONSIDERATIONS:
Moisture: (Dry / Clammy / Diaphoretic)

PAIN: (PQRSTUA) WOUNDS/DRSG/DUE2∆:

Analgesic:

J.SUBCHAK, 2023
 NURSING PRIORITIES TIMELINE MORNING HANDOVER REPORT
1

TO DO LIST NEW DOCTORS ORDERS

MEDICATION TIMES o
o
o
SCHEDULED MED LIST PRN MED LIST o
o
o
o
o

CHARTING CHECKLIST

o Vital Sign Record

o Diabetic Flow Sheet
o Signature Records x2
o MAR
o SCHMID/Falls Risk
o H2T
o IPN
o Other: ______________________

CEF CHECKED o
J.SUBCHAK, 2023