Document Code No.

CHS/BSN-CURR -RLEFORM-002h
Revision No. Effective Date Page No.
00 02.24.2023 1 of 2

MEDICAL AND SURGICAL MANANGEMENT

IDEAL RATIONALE/INDICATION ACTUAL REMARKS

IV FLUIDS Mainline ordered by the attending Purpose of IV therapy Current IV fluid/s hooked to the patient and If with or without IV and its
physician corresponding volume and rate reason/s

BLOOD AND BLOOD Identify if there is a need to secure blood Reason/s for Blood therapy Blood component and rate If with or without
PRODUCTS and blood products transfusion and its reason/s

MEDICATIONS Prescribed medications Purpose/s of medications Whether the medication is administered Given or not given
Pharmacological accurately and properly
parenteral, oral and
treatment

Alternative ways to alleviate Reason for nonpharmacological Whether there a relief of symptoms
Nonpharmacological discomfort/pain measures

DIAGNOSTIC TEST Laboratory test ordered by the doctor Reason/s for the test to be performed Whether the test was performed Performed or not
performed and its reason/s
 Document Code No.
CHS/BSN-CURR -RLEFORM-002h
Revision No. Effective Date Page No.
00 02.24.2023 2 of 2

PROCEDURE Surgical procedure/s ordered related to Reason/s for the procedure to be Whether the procedure was scheduled Performed or not
the plan of care performed performed and its reasons
Surgical

Evaluation Tool
UNACCEPTABLE
Medical and Surgical 1-10
Management Only a few (less than 75%) ideal and actual
management were listed; constraints
encountered as well as explanation of the
variation of the actual from the ideal were not
relevant and not indicated clearly
SATISFACTORY
11-15
Some (75-99%) ideal and actual management
were not listed; constraints encountered as well
as explanation of the variation of the actual from
the ideal were relevant and indicated clearly
EXCEPTIONAL REMARKS
16-20
Listed down all (100%) ideal and actual
management received by the patient; constraints
encountered as well as explanation of the
variation of the actual from the ideal were
relevant and indicated clearly