Nurse Report Sheet
Name
RM/Bed
Age/Sex ____________
M / F / NB
Doctor
CODE Status
•Full Code
•DNR
Allergies
Admit Date
Isolation
Admitting Dx
Pt Hx
IV access
IV fluids
Med Timings
PRN Meds
Mobility
•Independent •Assist
•Bedrest
•None •Contact •Droplet •Airborne
Labs
Diet
Labs
Vitals
WBC
BUN
Temp
RBC
Cr
SpO2
Hbg
Na
HR
HCT
K
RR
Platelets
Ca
BP
PT
Mg
Pain
PTT
BNP
Others
INR
Trop
Blood
Sugar
Urine
Output
Neuro
•Alert •Confused •Lethargic •Combative •Limb weakness
•Restraints/Bed alarms •Speech/swallow abnormal •HOH
Respiratory
•Clear •Wheezes
Cardiac
•Rhythm
Gastro/Urinary
•Foley •Feeding Tube
Skin
•Intact
•Echo EF
•Pressure Wound
Scheduled Procedures
•Edema
•Dressing Change
•Would Consult
Discharge
Notes
•Crackles
•Diminished
•Fluid Restrictions
•To Home
•CPAP
•BPAP
•Last BM
•Home Health
•Hospice
Nurse Report Sheet