Student's Name: ………….……………..…………………….……………..

Matrouh University Faculty of Nursing

Medical Surgical Department

NURSING RECORD
Patient’s name: ………….……………..…………………….…………….. Age: ……….……………….…………….……… Sex: ……….…………………….……………....
Diagnosis: …………………….……………..…………………….…………….... Admission date: ……….…………….activity Level: ……….……….……..
Hospital No: ……….…………….. Room No: ……….…………….. Bed No: ……….……………..……..… Diet: ……….………………….………………..
Date: ……/ …… /………… 9 10 11 12 1 2
Hospital day No: …… am am am MD pm pm NG Report
Pulse ● Temp x Resp 
BP
< 200 < 40
200 40
190 38
180 36
170 34
160 32
150 30
140 28
130 < 42 26
120 42 24
110 41 22
100 40 20
90 39 18
80 38 16
70 37 14
60 36 12
50 35 10
> 50 > 35 > 10
Pain severity
position Pain site
Exercise
Hygienic care

Fluid chart Intake Output Medications

Oral IV Others Urine Others Bowel Name Dose Route Site
9am
10 am
11am
12MD
1 pm
2pm
Balance
Signature