Name: _______________________________________________________ RLE Group/Section: _________ Hospital Area: _______________________

Clinical Instructor: _____________________________________________

KARDEX
NAME OF PATIENT: ______________ SEX: ________ AGE: ___________ RELIGION: ________________ ALLERGIES: _____________________________

ADDRESS: ______________________________________________________________________________________________________________________________________________

CHIEF COMPLAINTS: _____________________________________________ ADMITTING DIAGNOSIS: _______________________________________________________________

ATTENDING PHYSICIAN: ___________________________________________________ CO-MANAGEMENT: ____________________________________________________________

Date and Time Special Notation/Procedure Laboratory/Dx. Procedure Medication IV Fluid Diet

PREPARED BY: __________________________________________________ NOTED BY: ______________________________________________

VITAL SIGNS

Patient Name: _______________________________

Date Time Blood Pressure Body Temperature Pulse Rate Respiratory Rate Oxygen Saturation
Level

Patient Name: _______________________________

Date Time Blood Pressure Body Temperature Pulse Rate Respiratory Rate Oxygen Saturation
Level

INTAKE AND OUTPUT

Patient Name: _______________________________

Date Time Oral Fluid Intake IV Fluid Others Total

Patient Name: _______________________________

Date Time Oral Fluid Intake IV Fluid Others Total

MEDICATION

Patient Name: _______________________________

Date Time Generic Name Brand Name Classification Indication Dosage Frequency Route

Patient Name: _______________________________

Date Time Generic Name Brand Name Classification Indication Dosage Frequency Route