Title Page

  • Patient Name

  • Patient Room

  • Conducted on

  • Prepared by

General Information

  • Date of Birth

  • Sex

  • Admitted

Patient Report

  • Diagnosis

  • Procedure

  • Does the patient has allergies?

  • Please enter details

  • Patient medical history

  • Code status

Patient Monitoring - Vital Signs

  • Click + to add patient monitoring details

  • Patient Check
  • Time Check

  • Blood Pressure

  • Heart Rate

  • Temperature
  • Oxygen Saturation

  • Oxygen

  • Respiratory Rate

  • Pain

  • Blood Sugars

  • Are there dispensed medications?

  • Time of Med Pass

Intake

  • Breakfast

  • Lunch

  • Supper

  • Other

Output

  • Foley

  • BM

  • Emesis

  • Drains

  • Tubes

  • Ostomy Bag

Labs and Needed Procedures

  • Labs

  • Needed Labs

  • Future Procedures

Other

  • Discharge Plan

  • Variance to Discharge Plan: Barrier

  • Resolution

  • Consults

Completion

  • Click + to add Nurse On Duty

  • Nurse
  • Full Name and Signature of Nurse Attendee

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.