Isabela State University

City of Ilagan Campus

College of Nursing

Patient Chart

Date: Ward:

Shift: Age:

Name of Patient: Gender:

Patient’s Diagnosis: Address:

History (Medical/ Surgical):

Attending Physician:

_______________________
Students Nurse in-charge

_______________________
Clinical Instructor
 Area/ Ward:
Date:

Shift:

Activities for the day/ shift:

Time Initial care performed: Rationale

and
Date

Final care performed: Rationale

 LEVEL OF CONSCIOUSNESS

A-ALERT (NORMAL)
Monitoring Sheet D- DROWSY (CAN BE AROUSED)
S- STUPOROUS (LETHARGIC)
DATE TEMP BP PR RR 02 CBG INTAKE OUTPUT LOC PUPILLARY REFLEX EXT MOTOR C-COMATOSE
& SAT LEVEL
PULSE CHARACTERISTICS
TIME Rate Char Rate Char
L REACT- R REACT- RU RL LU LL F-FULL
TION ION I-IRREGULAR
T-THREADY
FT-FAINT

RESPIRATION CHARACTERISITIC

R-REGULAR
I-IRREGULAR
SH-SHALLOW
F-FAST
SL-SLOW
L-LABORED
A-APNEIC

MOTOR LEVEL

NORMAL +++
MODERATE ++
Diet: VERY WEAK +
PARALYZED 0
Blood:
PUPILLARY REACTION

PERRLA (Pupils are Equal, Round

and Reactive to Light and
Accommodation)
RB (Reacting Briskly)
RS (Reacting Sluggishly/ Slow)
DNR (Dilate and Nonreactive)
CNR (Constrict and Nonreactive)
 MEDICATIONS WITHIN THE SHIFT

Date: IV Fluids:

Shift: Regulation:

Drugs Incorporated:

Time started:
Time due:

DURATION/TIME MEDICATION ACTION

______________________________________

Student In-charge

______________________________________

Clinical Instructor