Nurse Report Sheet
Name/Initials
Age/Sex
Date:
RM #
[_] M [_] F
Admit Date
Admitting Dx
Anticip. D/C Date
Doctor
CODE STATUS
[_] FULL [_] DNR
ISOLATION
None Contact Droplet Airborne COVID
Allergies
Pt/Family Hx
IV Access
L R
IV Fluids
/
/
Diet
@
VITALS
Mobility
[_] Independent [_] Assist [_] Bedrest
Meds Timings
BP
RR
PR
SpO2
Temp
Pain
BS Ö
/10
/10
/10
PRN Meds
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Alert & Oriented X 1 2 3 4
NEUROLOGY
Lethargic
Confused
Combative
Speech / Swallow Abnormal
Weakness in Limbs
Restraints / Bed Alarms
Hard of Hearing
Rhythm
CARDIAC
o NSR AFIB SINUS BRADY
Echo / Stress Test
CHF
Paced
Intact
Pressure Wound
Dressing Change
Wound Consult
Scheduled Procedures
SKIN
Scheduled Consults
o
o
o
o
o
o
o
Clear
Crackles
Wheezes
Diminished
CPAP
BiPAP
HHN Tx
o
o
o
o
o
o
o
o
o
Foley
Feeding Tube
Fluid Restriction
Last BM
Urine
SCD
Coumadin
Levenox
Heparin
o
o
o
o
https://www.coursehero.com/file/87186766/Updated-Nurse-Report-Sheetpdf/
RESPIRATORY
O2 ________%
RA NC FM
LPM ________
GASTRO/URINARY
VTE
Notes
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______________________________________________
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Discharge
[_] source
Homewas[_]
Home Health
[_] Hospice
[_] SNF
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