Scribd Logo
Upload

Welcome to Scribd!

  • FORMAT

    Uploaded by

    wendy
    40 views3 pages
    This document contains a patient's medical information including their name, age, attending physician, admitting diagnosis, procedures, IV fluids, medications, vital signs, intake and output monitoring, assessment findings, and charting of focus, data, actions and responses. It provides a comprehensive overview of a patient's care through documenting key details.

    Original Description:

    Original Title

    FORMAT.docx

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document contains a patient's medical information including their name, age, attending physician, admitting diagnosis, procedures, IV fluids, medications, vital signs, intake and output monitoring, assessment findings, and charting of focus, data, actions and responses. It provides a comprehensive overview of a patient's care through documenting key details.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    40 views3 pages

    FORMAT

    Uploaded by

    wendy
    This document contains a patient's medical information including their name, age, attending physician, admitting diagnosis, procedures, IV fluids, medications, vital signs, intake and output monitoring, assessment findings, and charting of focus, data, actions and responses. It provides a comprehensive overview of a patient's care through documenting key details.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 3

    Student Nurse:______________________________ Date:_____________________

    PATIENTs DATA

    Patients Name:_____________________________ Age/Gender:______________

    Attending Physician:_____________________ Cc:_____________________________

    Admitting Dx:___________________________________________________________________________

    ______________________________________________________________________________________

    Procedures IVF Medications

    ____________________________ __________________________ ___________________________


    ____________________________ _ ___________________________
    ____________________________ __________________________ ___________________________
    ____________________________ _ ___________________________
    ____________________________ __________________________ ___________________________
    ____________________________ _ ___________________________
    ____________________________ __________________________ ___________________________
    ____________________________ _ ___________________________
    ____________________________ __________________________ ___________________________
    ____________________________ _ ___________________________
    ____________________________ __________________________ ___________________________
    ____________________________ _ ___________________________
    __________________________
    _
    __________________________
    _
    __________________________
    _
    __________________________
    _
    __________________________
    _
    __________________________
    _
    Assessment/Unusual Findings:

    ______________________________________________________________________________________
    ______________________________________________________________________________________
    ___________________________________________________________________________________

    Vital Signs:

    TIME BP PR RR CR TEMP. O2
    I & O Monitoring

    INTAKE OUTPUT
    IVF PO URINE STOOL/OTHERS

    FINAL I & O

    DATE/SHIFT INTAKE OUTPUT


    IVF PO URINE STOOL/OTHERS

    CHARTING

    DATE/TIME FOCUS DATA/ACTION/RESPONSE


    ____________ ________________ __________________________________________________________
    _ _ __________________________________________________________
    ____________ ________________ __________________________________________________________
    _ _ __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________
    __________________________________________________________

    You might also like