Forms Med Ward

Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND

Cabanatuan City, Nueva Ecija, Philippines
TECHNOLOGY
ISO 9001:2015 CERTIFIED
COLLEGE OF NURSING
Transforming Communities through Science and Technology

TECHNOLOGY
COLLEGE OF NURSING

TECHNOLOGY
COLLEGE OF NURSING

TECHNOLOGY
COLLEGE OF NURSING

TECHNOLOGY
COLLEGE OF NURSING
Patient Name: ____________________________________ Case number: __________
Date/Time Nurse’s Remarks

(DATE) 07:00 AM to 03:00 PM (DAY)
07:00 AM  Received on bed; awake
 Conscious and Coherent; conversant
 Febrile T- 39.2
 With IV fluid of ___________ 1L (or 500mL) at around _________ mL level and regulated
at ___________________gtts/min
 (IF WITH O2) With oxygen inhalation via nasal cannula at _________L/min
 (IF WITH NGT) With Nasogastric tube connected to bed side bottle, draining to
_________ output/intact.
 (IF WITH IFC) With foley catheter connected to urine bag draining to _________ output
 (IF WITH WOUND/OPERATIVE DRESSING) With wound dressing, dry and intact
 Vital signs taken and recorded
 (IF PATIENT IS FEBRILE) Temperature: ____ °C; warm skin and slightly flushed;
TIME tepid sponge bath done
 (IF THE STAFF NURSE GAVE PARACETAMOL IV) PARACETAMOL 300mg given
TIME intravenously by NOD
TIME  (AFTER 30 MINS) Temperature subsided to _____°C
TIME  (IF PATIENT IS HYPERTENSIVE) BP: ________ mmHg; pounding headache noted
 (IF THE STAFF NURSE GAVE ANTIHYPERTENSIVE) CAPTOPRIL/CLONODINE ____mg
TIME given sublingually
TIME  Latest BP: _________ mmHg
 Due meds given
 Nebulization done as prescribed
 (IF PATIENT IS FED VIA NGT) Osterized feeding done as prescribed
TIME  Seen and examined by Dr. ________________ with orders made and carried out
 (FOR SKIN TEST) Sensitivity skin testing of ___________ done on ______ forearm due at
TIME ___________
 (AFTER 30 MINS) Sensitivity skin testing of ___________ revealed (negative) as
TIME
interpreted by Dr. ________________
 (IF THE IV FLUID IS CONSUMED) Above IV fluid consumed and replaced with _______
TIME 1L/500mL and regulated at _____ gtts/min
 Intake and output measured and recorded
 All needs attended
TIME  Endorsed for continuity of care
(Student name) / (Clinical Instructor) / (Nurse on Duty)
NEUST SN’## / /

TECHNOLOGY
COLLEGE OF NURSING
 Present IV fluid of ______ removed aseptically and replaced with PNSS 1L and regulated at 10
TIME gtts/min
 Pre BT meds given (30mins before transfusion) (PARACETAMOL 300mg tab,
TIME DIPENHYDRAMINE 30mg, HYDROCORTISONE 20mg
 Above IV fluid reinserted aseptically using IV needle gauge 18 into left/right _______ vein and
TIME regulated at ________gtts/min
 Initial Vital signs as follows:
TIME  BP: T: PR: RR:
 1 unit of PRBC type ________ properly typed and cross-matched, checked by nurses on duty with
TIME serial number _________________ hooked as side drip and initially regulated at 10 gtts/min
TIME  Present Iv fluid stopped temporarily

 Vital signs as follows:
BP: T: PR: RR:
(after 5 mins) BP: T: PR: RR:
 No BT reaction noted (if none)
 Above BT unit regulated at 25 gtts/min
(after 1 hr) BP: T: PR: RR:
(after 1 hr) BP: T: PR: RR:
 Above BT unit consumed and removed aseptically; above IV fluid regulated at _________ gtts/min
TIME
 Latest Vital signs as follows:
TIME BP: T: PR: RR:
 Monitored closely for delayed reactions
 (IF TRANSFUSION REACTION OCCURS) Above BT unit discontinued temporarily; above IV fluid
TIME regulated at 10 gttss/min
BP: T: PR: RR:
TIME  Seen and examined by Dr. _________ with orders made and carried out
FOR BLOOD TRANSFUSION

TECHNOLOGY
COLLEGE OF NURSING
FOR DISCHARGE

TIME  Seen and examined by Dr. __________ with orders made and carried out
 May go home; to settle bills
 Discharge instructions given and properly explained
TIME  Above IV fluid discontinued/consumed and removed aseptically
TIME  Bills settled
TIME  Discharged via wheelchair; accompanied by SN and NOD
FOR ADMISSION

 In from Emergency Room/Ward/OR via stretcher/wheelchair
TIME
accompanied by NOD
 Transferred to bed safely; with IV fluid of _______ at around _______ mL
level and regulated at _______ gtts/min
 (IF WITH O2) With oxygen inhalation via nasal cannula at
_________L/min
 Admission care done
 Vital signs taken and recorded as follows:
Temp: PR:
RR: BP:
 (other interventions)
FOR IV REINSERTION

TIME  Pain and swelling on IV site noted
 Above IV fluid discontinued and removed aseptically and saved set;
TIME
warm compress placed on the IV site
 Above IV fluid reinserted aseptically using IV needle gauge ___ into
TIME
left/right _______ vein and regulated at ________gtts/min

TECHNOLOGY
COLLEGE OF NURSING
Sample Endorsement
 Present IVF
- c IVF of D5LRS 500 cc x 60 gtts/min @ _________
- TF: D5 0.3 NaCL 500 cc x 20-21 gtts/min
 q 8 Cefuroxime 80 mg IVP – (Next dose due)
 q 8 Gentamycin 15 mg IVP – (Next Dose due )
 V/S q 4 and recorded
 CBC result in x referral
 For U/A, F/A – done TSR
 I and O q shift
 Vol / Vol replacement
 Soft diet
- BRAT, BF c AP, MF c Al110, NPO
- Special instruction if any
-
Sample charting ADMISSION

TIME  In from ER cuddled by the mother / wheelchair
 Afebrile
 conscious
 c IVF of _______________ @ regulated at ___________
 Admission care rendered
Time  ST of meds and revealed a negative revealed a negative result done
Time  Initial dose of ________ given
 Diet reinstructed
 Temp increase T=
 TSB done reinstructed
 Temp increase T= _____
 TSB done and cold compress applied over the forehead
 Needs attended
 Endorsed

TECHNOLOGY
COLLEGE OF NURSING
Sample Charting
 Received pt awake on bed
 Febrile T-39.2 C
 Conscious
 Weak in appearance
 C slight sunken eyeball noted
 Not in respiratory distress
 C IVF of __________ @ _______ regulated at ______
 V/S taken and recorded
 MF of _______ instructed
 Due meds given
 TSB done and cold compress applied over the forehead
 Nebulization done
 Temp re-checked and subside to 38 C
 Continuous cooling measures rendered
 All needs attended
Extras
 Afternoon/morning care rendered
TIME  Above IVF consumed and replaced c _D5_________
 Seen and examine by Dr _______________ c orders made and carried out
TIME  Latest V/S
Others
TIME  c dislodged IVF of ___________ @ ______ level
 Above IVF of _______________________ @ ________ level reinserted at (site) and
regulated at ___________________
 CXR result in and referred to Dr ____________ c orders made and carried out

TECHNOLOGY
COLLEGE OF NURSING
Chart Arrangement
1. I & O monitoring sheet (if needed)
2. Medication Sheet
3. Patient Data Sheet
4. Patient Admitting History
5. Discharge Summary
6. Progress Notes
7. V/S Sheet
8. Laboratory Result
9. Physicians Order Sheet
10. Nurses Notes
Note: For Patient discharge should sign on the physicians order sheet (MGH ,HAMA)

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Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND

Transforming Communities through Science and Technology

Transforming Communities through Science and Technology

Transforming Communities through Science and Technology

Transforming Communities through Science and Technology

Patient Name: __________________________ Case number:

Date/Time Nurse’s Remarks

(Student name) / (Clinical Instructor) / (Nurse on Duty)

Transforming Communities through Science and Technology

TIME  Present Iv fluid stopped temporarily

Transforming Communities through Science and Technology

Date/Time Nurse’s Remarks

Date/Time Nurse’s Remarks

Date/Time Nurse’s Remarks

Transforming Communities through Science and Technology

Sample charting ADMISSION

Transforming Communities through Science and Technology

Transforming Communities through Science and Technology

Transforming Communities through Science and Technology

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