F. Cimafranca St.

,
Daro, Dumaguete City,
Negros Oriental
Tel. No. 523-5957
NURSES ACCOMPLISHMENT GUIDE SHEET

PATIENT’S NAME: _______________________________ AGE: _____ SEX: ______ DATE OF BIRTH: _________

DIAGNOSIS: ________________________________________________________________________________

BSA: ________ ATTENDING PHYSICIAN: ________________________________

VITALS SIGNS DATE: (d/m/yr) DATE: (d/m/yr) DATE: (d/m/yr)

Temperature
Pulse/Heart Rate
Respiratory Rate
Blood Pressure
CONSENT SIGNED

FLUID MONITORING:
Oral Intake: cc cc cc
IV Fluids cc cc cc
Output cc cc cc

PRE-MEDICATIONS

MEDICATIONS USED
AND GIVEN

CYCLE (WEEK/DAY)
TIME STARTED
TIME ENDED

HOME MEDICATIONS

REMARKS/ NURSES
NOTES

RN NAME AND
SIGNATURE
 F. Cimafranca St.,
Daro, Dumaguete City,
Negros Oriental
Tel. No. 523-5957