Date: _________________________ Preceptor: ____________________________ Student Name: ______________________________ Rm#
Name:
Age:
Rm#
Allergies:
Name:
Age:
Rm#
Allergies:
Name:
Age:
Rm#
Allergies:
Name:
Age:
Allergies:
Doctor/Consults:
Doctor/Consults:
Doctor/Consults:
Doctor/Consults:
Admitting date and diagnosis, events leading to hospitalization, what has happened since hospitalization
Admitting date and diagnosis, events leading to hospitalization, what has happened since hospitalization
Admitting date and diagnosis, events leading to hospitalization, what has happened since hospitalization
Admitting date and diagnosis, events leading to hospitalization, what has happened since hospitalization
Past Medical History:
Past Medical History:
Past Medical History:
Past Medical History:
Diet:
I/O:
Diet:
Activity:
Accu: AC &HS Other: Code Status:
I/O:
Diet:
Activity:
Accu: AC &HS Other: Code Status:
VS:
Resp Tx:
Monitor:
Wt:
I/O:
Diet:
Activity:
Accu: AC &HS Other: Code Status:
VS:
Resp Tx:
Monitor:
Wt:
I/O:
Activity:
Accu: AC &HS Other: Code Status:
VS:
Resp Tx:
Monitor:
Wt:
Resp Tx:
Monitor:
Wt:
O2
O2
O2
O2
IVs (solution, site, tbg, drsg, caps):
IVs (solution, site, tbg, drsg, caps)::
IVs (solution, site, tbg, drsg, caps)::
IVs (solution, site, tbg, drsg, caps)::
Wound/Tube Care:
Wound/Tube Care:
Wound/Tube Care:
Wound/Tube Care:
NG
NG
NG
NG
Foley CT JP Penrose Trach
Foley CT JP Penrose Trach
Foley CT JP Penrose Trach
VS:
Foley CT JP Penrose Trach
Meds:
Meds:
Meds:
Meds:
Report:
Report:
Report:
Report:
Labs/Diagnostics/Procedures to be done this shift
Labs/Diagnostics/Procedures to be done this shift
Labs/Diagnostics/Procedures to be done this shift
Labs/Diagnostics/Procedures to be done this shift
Room: Name: Abnormal and pertinent normal assessment findings: Neuro:
Room: Name: Abnormal and pertinent normal assessment findings: Neuro:
Room: Name: Abnormal and pertinent normal assessment findings: Neuro:
Room: Name: Abnormal and pertinent normal assessment findings: Neuro:
Pulm:
Pulm:
Pulm:
Pulm:
CV:
Rhythm:
CV:
Rhythm:
CV:
Rhythm:
CV:
Gi/Gu:
Gi/Gu:
Gi/Gu:
Gi/Gu:
M/S:
M/S:
M/S:
M/S:
Integ:
Integ:
Integ:
Integ:
Rhythm:
Pain Management:
PCA:
Pain Management:
PCA:
Pain Management:
PCA:
Pain Management:
PCA:
Vital signs:
Accucheck:
Vital signs:
Accucheck:
Vital signs:
Accucheck:
Vital signs:
Accucheck:
I/O:
I/O:
I/O:
I/O:
Critical/Priority lab/diagnostic test results
Critical/Priority lab/diagnostic test results
Critical/Priority lab/diagnostic test results
Critical/Priority lab/diagnostic test results
Other:
Other:
Other:
Other:
New Orders:
New Orders:
New Orders:
New Orders:
Patient Education this shift / needs:
Patient Education this shift / needs:
Patient Education this shift / needs:
Patient Education this shift / needs:
Discharge Plans:
Discharge Plans:
Discharge Plans:
Discharge Plans:
Shift Goals
Shift Goals
Shift Goals
Shift Goals