Name of Student:___________________________________________ Religion: _________________

Name of Pateint:___________________________________________ Date of Adm.:_______________
Age:_________

Attending Physician:________________

Chief Complaint:_________________________________________________________________________________________________________
Marital Status:________________________________

Medical Diagnosis:_____________________________________
General Objectives:___________________________________________
Diet

Laboratory/Diagnostic Exam
Results

Special Endorsement

Nursing Diagnoses (3 priority)

VITAL SIGNS

T
I
M
E

Temp

PR

IVF / BLOOD

BP

RR

O2
Sat

INTAKE
Time

oral

tubal

parenteral

Order
Reg.

Name
And
Volume

I/O

TOTAL

Time

Level

IVF to Follow

OUTPUT
Urine

Suctin

TOTAL
No. of Stools:
No. of Urine:

Amount
Co

Patient Name:

Others

TOTAL

Date

Shift

Signature

Patient Name:

MEDICATION
Generic Name (Brand) Dosage, Route,
Frequency

No. of
Stocks
Received

Timing of
Frequency

Nursing Precaution/Resp. Before, During, after giving med

MEDICATIONS
Patient Name:

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