Name of Patient:

Age: Sex: Room No. Case No.

Date/ FOCUS DATA ACTION RESPONSE

Time Shift

ER Initial VS
Admission BP: ______________ ⃢ Consent for
Temp: ____________ admission secured.
PR: ______________ ⃢ Seen and examined
RR: ______________ by Resident Physician
SPO2: ___________ ⃢ Diagnostic test
Wt.:______________ required.
FHT:_____________ ⃢ ECG
⃢ X-ray
Neuro VS __________
Pupils:__________ ⃢ CT Scan
GCS:____________ _______
E: ___________ ⃢ UTZ
V: ___________ ___________
M: ___________ ⃢ Lab/s
__________
Other Findings: ____________
____________

⃢ Contraptions
Inserted
⃢ IVF ___________
⃢ FC
⃢ NGT
⃢ Others:
________

⃢ Plan:
____________
Surgeon/OB_______
Anesth __________
Pedia ___________

⃢Under the service of

___________
⃢ Attending physician
informed
________________

⃢ Transformed to
room of choice with
assistance.

⃢ Endorsed to nurse
on duty.
________________________
Signature Over Printed Name
Nurse On-Duty