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University of Pangasinan

University of Pangasinan

College of Nursing Dagupan City, Philippines

College of Nursing Dagupan City, Philippines

Agency: Date: Name: Address: Medical Dx: Dr. Height: Weight:

Room No. Age:

Intake: Output: Vital Signs Q

Agency: Date: Name: Address: Medical Dx: Dr.

Room No. Age:

Height: Weight: Vital Signs Q

Time: T(°C): PR(bpm): RR(cpm): BP(mmHg): Pain(0-10):

Time: T(°C): PR(bpm): RR(cpm): BP(mmHg): Pain(0-10): IV Fluids

IV Fluids

Name: Received: gtts/ml: (set) gtts/min: (order) Endorsed: Amount Infused: Empty @: Name

Name: Received: gtts/ml: (set) gtts/min: (order) Endorsed: Amount Infused: Empty @: Meds Dose

Time

Nurse’s Note

Route

Name

Meds Dose

Time

Nurse’s Note

Route