Room#: _______ GoC:________Date:___________

Allergies: Age/Sex: Report:

Diet/Fluids: Mobility:
O2 therapy: VS sched:

Time To Do To Chart Meds Given/Notes

0600/1400 Turn on flags Vitals PRN meds before
Review orders IV check shift:
Review meds
Review labs
Review paper chart
Pt appointments
How long has pt been in hospital? PRN meds during
__________________ shift:
Why is pt admitted now? _____
Where will pt be discharged? When?
____________________
0700/1500 Meds: ____________________________ H-T assessment
Safety: suction, O2, call bell, rails, ID/agy
IV check
Vitals:
BP: ________ Temp: ______
HR: _____; quality: _________
Resp: ____ O2: _____ on ______
Chest pain, SOB: Yes No
LOC: Person Place Time
H-T assessment
0800/1600 Meds: ____________________________
Establish nursing priorities


0900/1700 Meds: ____________________________



1000/1800 Meds: ____________________________



1100/1900 Meds: ____________________________
Vitals
BP: ________ Temp: ______
HR: _____; quality: _________
Resp: ____ O2: _____ on ______
Chest pain, SOB: Yes No
LOC: Person Place Time
1200/2000 Meds: ____________________________
Report off

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