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Audit

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

Nurse Shift Report Sheet Checklist

Created by: SafetyCulture Staff | Industry: Health Services | Downloads: 4

This Nurse Shift Report template can be used and customized to record vital patient information. Outgoing nurses use a nurse shift report to keep track of patient's diagnosis, attending doctor, consults, critical lab values, and medication history and pass it on to the oncoming nurse. This digital template allows attachment of photos, assignment of tasks, and digital sign-offs to help streamline the nurse shift reporting process.

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Audit

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