PATIENT INFORMATION

NAME RM # AGE SEX

CODE STATUS PAST MEDICAL HISTORY ALLERGIES DIET

MRP NURSE
ADMIT DATE MOBILITY

ADMIT REASON
TESTS/PROCEDURES SAFETY (LOC, falls risk, psych, restraints, alarms)

PRIMARY DIAGNOSIS

NEURO
VITALS

TIME: TEMP: HR: BP: RR: SAO2: BS: PAIN:

TIME: TEMP: HR: BP: RR: SAO2: PAIN:

TIME: TEMP: HR: BP: RR: SAO2: PAIN:

CARDIAC TIME: TEMP: HR: BP: RR: SAO2: BS: PAIN:

TIME: TEMP: HR: BP: RR: SAO2: BS: PAIN:

PLAN OF CARE TO DO

0600: Patient research

0700: Patient handover, Initial approach, VS, H2T,

documentation
RESPIRATORY 0800

LABS 0900

K+ PLT

NA+ HGB 1000

GI/GU MG HCT

CA WBC 1100

PHOS GLUC

CREAT TROP 1200

BUN PTT

SKIN INR GFR 1300

UREA OTHER

NOTES 1400

1500

MUSKULOSKELETAL

1600

1700

LINES/DRAINS/TUBES 1800
 MEDICATIONS
TIME DUE NAME AND DOSE IMPORTANT SIDE EFFECTS NOTES