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FutureNurseAnya ClinicalSheet

This document contains information about a patient's hospital admission including their admitting diagnosis, code status, admission date, orientation, oxygen needs, diet, bowel status, safety risks, lines/tubes/drains/wounds, vital signs, pain levels, physical assessment findings, labs, medical history, social history, medication schedule, blood thinner status, and notes on allergies and consults.

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40 views1 page

FutureNurseAnya ClinicalSheet

This document contains information about a patient's hospital admission including their admitting diagnosis, code status, admission date, orientation, oxygen needs, diet, bowel status, safety risks, lines/tubes/drains/wounds, vital signs, pain levels, physical assessment findings, labs, medical history, social history, medication schedule, blood thinner status, and notes on allergies and consults.

Uploaded by

pdfsellss
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Room #: ____ Name: _______________ Age: ____ Admitting Diagnosis:

Code Status: __________ Admitted Date: __________


A&O x ___ : ⼞ Person ⼞ Place ⼞ Time ⼞ Situation
Oxygen: ____________ Diet: _________ BS: Y/N HPI:
Safety / Falls Risk: ____________________________
Continent / Incontinent: ⼞ Foley ⼞ External Cath ⼞ Chucks

Lines/Tubes/Drains/Wounds Labs
Gray 16
Green 18
Hgb INR
Pink 20 WBC Plt
Hct PT PTT PMH / Comorbidities:
Blue 22
Yellow 24

Hi
Na Cl BUN
Gluc
K CO2 Creat

Social / FHx:
Ca TP AST LDH
Bili
PO4 Alb ALT AP
Medication / Care Schedule Blood Thinner: Y/N

0700
Vital Signs
Time _____ Time _____ Time _____
0800
BP ___ / ___ BP ___ / ___ BP ___ / ___
HR ___ HR ___ HR ___
SpO2 __% SpO2 __% SpO2 __% 0900
RR ___ RR ___ RR ___
T ___ T ___ T ___
1000
Pain _______ Pain _______ Pain _______

1100
Head to Toe Assessment
Neuro

1200
Respiratory

Cardiac
1300

Peripheral Vascular

1400
GI

GU
1500
MSK

1600
Skin

Allergies: Consults:
Notes:

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