Nurses.docx

NURSES ‘ NOTES 1. Date …………………………………. Time :…………………………………….. a) Direct admission : A new patient Ms. / Mr…………………admitted in …………..ward under Dr……..with the c/o ( e.g. fever , vomiting , pain , loose motion ) . Patient came by trolley /wheel chair /by walk .Patient is conscious , oriented , unconscious . Vital signs are checked and recorded on TPR sheet . Initial assessment done . ID band tied . Signature of employee ID b) Transfer in from other hospital A new patient Ms. / Mr…………………admitted in …………..ward under Dr……..with the c/o ( e.g. fever , vomiting , pain , loose motion ) . Patient was received with vein flow, catheter , RT, Central line , edema , Phlebitis , Bed sore . Vital signs are checked and recorded on TPR sheet . Initial assessment done . ID band tied . Signature of employee ID 2. Date …………………………………. Time :…………………………………….. a) Cash Patient Mr / Ms. …………………..under Dr. ………….was admitted on ………and was diagnosed as case of ……………….Patient is getting discharged with discharge medication and instruction . All extra medicine are returned . All due medicine before discharge given to the patient . health education about discharge medicines and discharge follow up are explained to the patient and attendants . Patient’s reassessment is done , general condition : stable / poor/fair/average . All invasive lines removed before sending the patient . All investigations reports , bills handed over to attendants . ID band removed. No dues . No. …………..Patient was shifted on wheelchair / stretcher /by walking Signature of employee ID b) TPA Patient Mr / Ms. …………………..under Dr. ………….was admitted on ………and was diagnosed as case of ………………. Patient underwent surgery ……..dressing intact , drainage bag on left /right side . all due medicine given before discharge . All extra