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Nursing Report Sheet (Revised For Neuro)

This document contains fields for recording a patient's admission information including their name, age, vital signs, admission date and reason, current medical problems, allergies, activity level, diet, neurological exam, skin exam, and notes for recent procedures, labs, intake and output, medications, and re-evaluation. It provides a way to document the essential details of a patient's admission on one page.

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HayleyLangley
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12K views1 page

Nursing Report Sheet (Revised For Neuro)

This document contains fields for recording a patient's admission information including their name, age, vital signs, admission date and reason, current medical problems, allergies, activity level, diet, neurological exam, skin exam, and notes for recent procedures, labs, intake and output, medications, and re-evaluation. It provides a way to document the essential details of a patient's admission on one page.

Uploaded by

HayleyLangley
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Room#

Pt Initials:
POA:
Code:

M / F
Age:
HT:
WT:

Pref. name:
Isolation:

Family/Contact Info:

Accucheck: Y / N
Restraints: Y / N

Admit Date:

Admit Reason(s):
Current Problems:

Allergies:

Activity:

Vitals:
HR:
BP:
RR:
Temp:
Shift:
SPO2:
PIV / CVC / PICC #1
R / L site:
Fluid/Rate:

RN:
Instructor #:
1

Diet:
Neuro:
Resp:

PIV / CVC / PICC #2


R / L site:
Fluid/Rate:

PIV / CVC / PICC #3


R / L site:
Fluid/Rate:

GI:
GU:

Cardiac:

Tele/Pack#

Void Status:
Last BM:
Medical History:

Skin:

M/S:
Pain:

RUE:
LUE:
Other Notes:

RE-EVAL

Recent Procedures:

RLE:
LLE:

#
2

Labs:
K:
Mg:
Na:
Ca:
Troponin:
BNP:
EF:
PT:
INR:
ALT/AST:
Hgb:
Hct:
RBC:
WBC:
Albumin:
Platelet:
Cr:
BUN:
GFR:
PO2:
PCO2:
HCO3:
pH:
Chol:
Lipid:
LDL:
HDL:

I/O Notes:

Meds:
______ __

________ _

_______ _

________

________

___ ____

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