Student Name
Date
Inpatient
Observation
Bedside Shift Report / Hand-off Communication Sheet
S
B
Chief Complaints
Diagnosis
Medical-Surgical Hx
Infection Control
MRSA
Y
RVP
Y
C-Diff
Y
A
Cardio
WNP Troponins/Time
Rhythm:__________ #1___________/_________
DW: Y N
#2___________/_________
Non-tele
#3___________/_________
Pulm
WNP
O2 Sat:
GI/GU
Foley IN:
WNP
Out:
MUSCULOSKELETAL
C
Contact
N
WNP
Date: ____________
Date: ____________
AMI
Stroke
SCIP/LOA
Need Follow up:
ctivity
Skin/Wound/Dressing
POCT
S&S
Insulin:
AC&HS
Low
Q6H
Med
Consult
Code Status
Full
DNR
Declined
Declined
Pneumonia
CHF
Anesthesia End time ________
Ambulatory
PT
Bed Rest
OT
utrition
NPO
Consult: Y N
IV
Site _________________
SL/CVC/Port/Dialysis Cath
Date ______________________
IVF:
Weight
ore Measures
A
WNP
Height
Baseline Vis
V/S Frequency
BP
HR
RR
T
02 Sat
Med Recon:
Y
Elopement
N
Baker Act
N
N
N
Seizure
Droplet
PUP
Airborne
Vaccines
Flu Vac Rec’d:
Pneumo Vac Rec’d:
WNP
Gender
Allergies
Precautions
Fall
Neuro
Age
Diet________________________
Swallow Eval Passed: Y N
D
VT Prophylaxis
Lovenox
Coumadin
Heparin
High
I
nfection
SCD
Arixtra
Xarelto
CVC
Pradaxa
Other ____________
Contraindicated
BC
Sputum Cx
Foley
Urine Cx
Home
HHC
ALF
NH
Tx to Hospital
Rehab
Antibiotic/s___________________________
R
Pain
#________
Pain Meds:

Re Assess IV&IM 30 min PO – 60 min
Procedures
Nursing Diagnoses
D
ischarge
Abnormal and Pertinent Diagnostic Exams and Labs
Nursing Note
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________