Nursing Report Sheet

Name: DOB: Name: DOB: Name: DOB: Name: DOB:

Room # Code: Team: Room # Code: Team: Room # Code: Team: Room # Code: Team:
Allergies: Isolation: Allergies: Isolation: Allergies: Isolation: Allergies: Isolation:
From: Flag: From: Flag: From: Flag: From: Flag:

DX: DX: DX: DX:

DX: DX: DX: DX:

Alert & Oriented x __, ________ Alert & Oriented x __, ________ Alert & Oriented x __, ________ Alert & Oriented x __, ________
Risk: Aspiration/ Risk: Aspiration/ Risk: Aspiration/ Risk: Aspiration/
Seizure/Fall/______ Seizure/Fall/______ Seizure/Fall/______ Seizure/Fall/______
Pills: Whole / Crushed Pills: Whole / Crushed Pills: Whole / Crushed Pills: Whole / Crushed

Respiratory: Respiratory: Respiratory: Respiratory:

O2: Room Air / ____ L/min O2: Room Air / ____ L/min O2: Room Air / ____ L/min O2: Room Air / ____ L/min
Bipap/Cipap Bipap/Cipap Bipap/Cipap Bipap/Cipap
Cough: Cough: Cough: Cough:
Lung Sounds: Lung Sounds: Lung Sounds: Lung Sounds:

Cardiac: Cardiac: Cardiac: Cardiac:

Regular/Irregular Regular/Irregular Regular/Irregular Regular/Irregular
Pacemaker/Tele/ Pacemaker/Tele/ Pacemaker/Tele/ Pacemaker/Tele/
Pulse: Pulse: Pulse: Pulse:
Edema: Edema: Edema: Edema:

GI & GU: GI & GU: GI & GU: GI & GU:

Diet:
Cont / Incont: Foley/ Urinal/
Bedpan/ Commode/__________
Last BM: ________ Type:______
Complains:_____________
Diet:
Cont / Incont: Foley/ Urinal/
Bedpan/ Commode/__________
Last BM: ________ Type:______
Complains:_____________
Diet:
Cont / Incont: Foley/ Urinal/
Bedpan/ Commode/__________
Last BM: ________ Type:______
Complains:_____________
Diet:
Cont / Incont: Foley/ Urinal/
Bedpan/ Commode/__________
Last BM: ________ Type:______
Complains:_____________

Baseline Mobility: ___________ Baseline Mobility: ___________ Baseline Mobility: ___________ Baseline Mobility: ___________
Current: Ind/Supervision/ Lift/ Current: Ind/Supervision/ Lift/ Current: Ind/Supervision/ Lift/ Current: Ind/Supervision/ Lift/
assist x assist x assist x assist x
____/Cane/Walker/WC/ _____ ____/Cane/Walker/WC/ _____ ____/Cane/Walker/WC/ _____ ____/Cane/Walker/WC/ _____

Skin: Skin: Skin: Skin:

Dressing: Dressing: Dressing: Dressing:

Lines/Tubes/Drains: Lines/Tubes/Drains: Lines/Tubes/Drains: Lines/Tubes/Drains:

IV:_______PICC:______HD:___ IV:_______PICC:______HD:___ IV:_______PICC:______HD:___ IV:_______PICC:______HD:___
Other: Other: Other: Other:

Barriers to Discharge: Barriers to Discharge: Barriers to Discharge: Barriers to Discharge:

Note/Reminder: Note/Reminder: Note/Reminder: Note/Reminder: