Claire Julianne T.

Capati
BSN – 1A

HOSPITAL FORMS
1. Fact Sheet
- Patient data, including the patient’s name, address, phone number, next of kin,hospital
identification number, religious preference, place of employment,insurance
company,occupation,name of admitting physician,and admitting diagnosis.

2. Physician's Orders
- The physicians directives for patient care.

3. Graphic sheet
- Record of serial measurements and observations, such as temperature,pulse,respiration,blood
pressure,weight..

4. Nursing Care plan

- Care plan for the patient,including the nursing diagnosis,goals and expected outcomes,and
nursing interventions.

5. Nurse's Notes
- Written report of the nursing process(assessment,nursing
diagnosis,planning,implementation,and evaluation);record of intervention implemented and the
patients response to them.

6. Care flow sheet

- Form on which check marks or short entries are made to indicate dietary intake, types of bath,
wound dressing changes,oxygen in use, physicians orders, equipment in use,level of activity and
so forth.

7. Medication Administration Record(MAR)

- Documentation of all medications ordered, dosage given, and doses not taken by the patient.

8. History and Physical Examination Forms

- Physicians record of the patients medical history and findings of the current physical
examination

9. Nurse's admission history and assessment

- Nurse's current history,including usual habits,medications usually taken,and physical assessment
findings at admission.

10. Progress Sheet

- Physicians note regarding the patients progress

11. Laboratory reports

- Results of laboratory tests
12. Radiology Reports
- Results of x-ray examinations

13. Admission Forms

- Information on patient identification, conditions for admission, and consent for general medical
and nursing care

14. Input and output

- Serial record of 24-hour intake and output

15. Ancillary staff sheets

- Records of treatment by physical therapists, occupational therapists, respiratory therapists, and
so forth.

16. Consultation Sheet

- Record of another physician called in to consult by the attending physician.

17. Diabetic Flow sheet

- Record of blood glucose determinations and amounts of insulin administered.

18. Discharge Form

- Information about instructions given regarding wound care, medications, rest, activity
restrictions,needed exercises, diet,and signs and symptoms to report to the physician, also
includes when to next see the physician.

19. Discharge Planning Sheet

- Records by social services, home health agencies, case managers, and clinical nurse specialist
regarding the discharge plans and patient needs.

20. Fall Risk assessment

- Information regarding the patients potential fall risk;particularly used for frail,elderly, or
patients with intramuscular impairments .

21. Frequent observations Sheet

- Used when frequent measurements of vital signs or neurological assessments are needed
(EX:after surgery or after head trauma.)

22. Intravenous (IV) Flow sheet

- Record of IV fluids and additives infused, type of IV catheter in use,data tubing was changed,
date dressing was applied.

23. Pain assessment

- Record of pain level,when assessed, measures to reduce it , effectiveness of treatment.

24. Preoperative checklist

- List used to verify that the patient is ready to go to surgery.
 25. Skin Risk assessment
- Data from thorough skin assessment on admission, evaluation of risk factors for skin
breakdown;diagrams showing areas of redness, breaks in the skin,or pressure ulcers.

26. Surgical or Treatment consent form

- Patient authorization for surgery or treatment

27. Time-out Form

- Patient verification,site mark verification, and time out performed before a surgical procedure

28. Transfer Form

- Information pertinent for the transfer of the patient to another unit or facility.

REFERENCE:
https://quizlet.com/150148214/identify-the-different-types-of-forms-used-for-hospital-documentation-
flash-cards/