NURSE Report

PATIENT BACKGROUND
Name: Age: Sex: Male Female Room #: MD:
Complaint: Mobility: Indep Assist Bedrest Code: Full DNR Limited

Allergies: Admit Date:

Diagnosis: Medical History Situation Precaution
CAD BPH MI Fall Risk Confused None Droplet
Restraints Suicide Contact Airborne
CABG AFID Anxiety
Aspiration Seizure
AAA PVD Stroke

HTN HLD TIA Hospital Course:

Tests/Procedures:
CHF DLD Depression
Pacemaker Cath ETT EKG Echo
COPD ETOH GERD
X-Ray MRI EGD CT
CKD DM PAD

NEURO VITALS MEDICATIONS & TO DO

A&O x Unconscious Confused Temp BP HR RR SpO2 Time Task
Power Reflex RASS

Notes:

CARDIAC
Pulses Edema Cardiac Sounds
ACCU CHECK
Bilateral
AC HS Hourly
Notes:
Time BS Cover

RESPIRATORY
Pattern Chest Exp Clear
Diminished Crackles Breath Sounds
Room Air CPAP BIPAP
Vent
Notes:
LABS
GASTROINTESTINAL
Diet: Regular NPO Tube Feed Na Cl BUN
Glucose
Intake Calories Ostomy K CO2 Cr
Last BM: Hypo Normal Hyper
Notes: HGB PT PLAN OF CARE
WBC PLT INR
GENITOURINARY HCT PTT
Output Voiding Incontenance
Ca+ Mg+ Phos
Anuria Urinal Bedside Comm

Catheter Bedpan Trop

Notes:
SKIN:
MUSCULOSKELETAL: DISCHARGE PLAN
Numbness: RUE LUE RLE LLE
Weakness: RUE LUE RLE LLE
SBA AD LIB Assisting Device
Notes:

DRIPS/FLUIDS:
SCHEDULED PROCEDURES
a
IV SITES: Cath Echo EKG Pacemaker
a
PIV PICC MRI X-Ray CT US/Dopplers
a
Central Other Bone Scan Mammography
PIV PICC CVC HD

CONSULTS: NOTES:
GI PT/OT Psych Neuro
Ortho Onco Nephro Pulmo
Medi Urology Speech Surg
Cardio
NURSE Report
PATIENT BACKGROUND
Name: Age: Sex: Male Female Room #: MD:
Complaint: Mobility: Indep Assist Bedrest Code: Full DNR Limited

Allergies: Admit Date:

Diagnosis: Medical History Situation Precaution
Fall Risk Confused None Droplet
Restraints Suicide Contact Airborne
Aspiration Seizure

Hospital Course:
Tests/Procedures:

NEURO VITALS MEDICATIONS & TO DO

Temp BP HR RR SpO2 Time Task

CARDIAC
ACCU CHECK
AC HS Hourly

Time BS Cover

RESPIRATORY

LABS
GASTROINTESTINAL
Na Cl BUN
Glucose
K CO2 Cr

HGB PT PLAN OF CARE

WBC PLT INR
GENITOURINARY HCT PTT

Ca+ Mg+ Phos

Trop

SKIN:
MUSCULOSKELETAL: DISCHARGE PLAN

DRIPS/FLUIDS:
SCHEDULED PROCEDURES
a
IV SITES: Cath Echo EKG Pacemaker
a
PIV PICC MRI X-Ray CT US/Dopplers
a
Central Other Bone Scan Mammography
PIV PICC CVC HD

CONSULTS: NOTES:
GI PT/OT Psych Neuro
Ortho Onco Nephro Pulmo
Medi Urology Speech Surg
Cardio
Patient History
PATIENT NAME: D.O.B: DATE:
PRESENTING COMPLAINT

HISTORY OF PRESENTING COMPLAINT

MEDICAL & SURGICAL HISTORY MEDICATIONS

ALLERGIES

FAMILY HISTORY SOCIAL/DAILY LIFE HISTORY

EXAMINATION/NOTES