KARDEX
DATE LABORATORY DATE NURSING PROCEDURE
DATE IVF DATE MEDICATION
NAME: _______________________________________ AGE: ______ SEX: ______ STATUS: _________
HEALTH RECORD NO.: _________________________
BIRTHDAY: _______________________ WEIGHT: ____________
DATE ADMITTED: _______________________ DIET: __________________________________________
CHIEF COMPLAINT: _____________________________________________________________________
DIAGNOSIS: ___________________________________________________________________________
FINAL Dx/PROCEDURE DONE: ____________________________________________________________
ATTENDING PHYSICIAN: _________________________________________________________________
ADDRESS: ____________________________________________________________________________
NURSES NOTES
DATE/ FOCUS DATA/ACTION/RESPONSE
TIME
Name of Patient:______________________Age/Sex: ______ Health Record No: ______ Ward: ______
Hospital Name: Hospital Code:
Surname: Age: Health Record no:
Given Name: Gender: Ward/Room/ PHIC Class:
DOCTOR’S ORDER SHEET
Progress Date DOCTOR’S ORDERS C A R E D Time
Notes Time Posted
Signature
INTRAVENOUS FLUID SHEET
Date Shift Bottle Solution Volume Flow Time Remarks Nurse on Duty
No. Rate Started
Ended
Name: __________________________________ Age/Sex: ______ Health Record No: ______________
MEDICATION SHEET
DAT MEDICATION Shift
E
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
Name: __________________________________ Age/Sex: ______ Health Record No: ______________
TPR SHEET
FLUID INTAKE AND OUTPUT MONITORING FORM
Intake Output
Date Shift Oral Intravenous NGT Others Total Urine Stool Others Total
7am
-
7pm
7pm
-
7am
Tota
l
7am
-
7pm
7pm
-
7am
Tota
l
7am
-
7pm
7pm
-
7am
Tota
l
7am
-
7pm
7pm
-
7am
Tota
l
Name: __________________________________ Age/Sex: ______ Health Record No: ______________
FLOW SHEET
Date Time BP T P R O2 Others Remarks NOD
Name: __________________________________ Age/Sex: ______ Health Record No: ______________
TEMPERATURE MONITORING FORM
Time ROOM REFRIGERATOR
Date Temp Remarks NOD Temp Remarks NOD
2am
6am
10am
2pm
6pm
10pm
2am
6am
10am
2pm
6pm
10pm
2am
6am
10am
2pm
6pm
10pm
2am
6am
10am
2pm
6pm
10pm
2am
6am
10am
2pm
6pm
10pm
Name: __________________________________ Age/Sex: ______ Health Record No: ______________
TPR SHEET
Room Patient’s Name BP T P R O2 OFI U S
/
Bed#
HOSPITAL DAILY CENSUS REPORT
For 24 hours ended midnight of: Date_________________ Ward/Unit ________________
ADMISSIONS DISCHARGES
Case Time Name of Patient Classification Case Time Name of Patient Classification
No. No.
Trans-in from other Ward/Unit Trans-out to other Ward/Unit
Case Time Name of Patient Ward/Unit Dept/Class. Case Time Name of Patient Ward/Unit Dept/
No. No. Class.
DEATH
Case No. Time Name of Patient Ward/Unit Classification
Last Census Admission Trans-in Discharge Trans-out Death Present PHIC
Census
Male
Female
Total
CENSUS SUMMARY FOR THE DAY
1. Remaining from yesterday’s midnight report _________________
2. Admission _________________
3. Trans-in from other ward/unit _________________
4. Total of Nos. 1, 2, 3 _________________
5. Discharges (Alive) this census day _________________
6. Trans-out to other ward/unit _________________
7. Deaths _________________
8. Total of Nos. 5, 6, 7 _________________
9. Remaining at 12:00 midnight (4) minus (8) _________________
10. Number of admitted then discharged on same day _________________
11. Total in-patients service days of care _________________
Prepared by: __________________________ Date: __________________
Nurse on Duty Checked by: _________________________
Nurse Supervisor