AM REPORT
Room:
Age:
Sex:
Admit date:
Doctors:
Brief history of why admitted:
Admitting Diagnoses:
PMH/Medical/Surgical diagnosis:
Psychosocial:
Allergies:
Code status:
Specific Labs/Diagnostic Tests (Needs observation during shift):
IVs:
Average vital signs:
Diet:
Nursing Concerns/considerations/risks:
Документ1
3 NANDAs with related to statements (Pre-care/Post-care) 3
Interventions for first 2 NANDAs:
1)
2)
3)
Timeline:
Diet
0630
Документ1
Activity
0730
0830
Vital Signs Schedule
0930
1030
1130
Foley
1230
I&O
1330
1430
Misc
1530
1630
Medication Groupings (Why patient is receiving)
Документ1
Laboratory/Diagnostic Testing Groupings (why patient had
performed)
Документ1