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Comprehensive Patient Care Documentation

Nurses Notes

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Ayen Miguel
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0% found this document useful (0 votes)
11 views13 pages

Comprehensive Patient Care Documentation

Nurses Notes

Uploaded by

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

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

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