This is a general checklist of what the unit/ ward nurse is supposed to accomplish within the EMR within the

shift

Directions: The system will write " YES" if DONE and "X" if NOT DONE

DAILY CHECKLIST
0 Date:
AM PM NIGHT PRN AM PM NIGHT PRN
VS
I/Os
MAR
NCP

Monitoring

Fall
Assessment

Skin
Assessment

Health
Teachings

Laboratory
Results
Checking
Health
Assessment

Date: (MM/DD/YYYY) Date:

AM PM NIGHT PRN AM PM NIGHT PRN
VS
I/Os
MAR
NCP
Monitoring
Fall
Assessment
Skin
Assessment
Health
Teachings
Laboratory
Results
Checking
n the EMR within the shift.

Date:
AM PM NIGHT PRN

Date:
AM PM NIGHT PRN
Head-to-toe Assessment Date:
Assessment conducted by: MonicaL. BorTime:

LOC
Drow Leth Strap
Alert sy argic orous
Orientation
Person
Place
Time
Situation
Vitals
Temp 36.8 R: 102 cpm
BP 124/84 mmHg PulseOx: 92%
Head
Hair
PERLA
Nose
Ears
Mouth
Midline tongue
Moist
Lesions
Dentitions
Neck
Carotid Pulse JVD+ Trachea midline
Chest
Muf Arryt
ApicalPulse ed hmia
Breath Sounds Anterior Posterior Lateral
Chest Symmetry
Skin Turgor(clavicle)
Abdomen
Inspection: globular
□Auscultation
□ LUQ (active / hyper / absent) Active ✘ Hyper ✘ Absent
□ RUQ (active / hyper / absent) Active ✘ Hyper ✘ Absent
□ LLQ (active / hyper / absent) Active ✘ Hyper ✘ Absent
□ RLQ (active / hyper / absent) Active ✘ Hyper ✘ Absent
□Palpation: soft, non-tender

Upper Extremities
□Radial Pulse
◦ other:
 □ Temp vsTrunk (warm / cool)
✘ □Grip equal and strong_______________
✘ □Capillary refill <2 sec
□ Vein Filling________________________

Lower Extremities
Hair present
Edema
Foot Strength
Homan's Sign ✘ (-) (+)
Temp vs trunk ✘ warm cool
Yellow Ingro
Nails ed Thickened wn
Pedal
ROM Strength
□ Upper R □ Upper R
□ Upper L □ Upper L
□ Lower R □ Lower R
□ Lower L □ Lower L
□ Sensation

General Assessment
Weight: 156 lbs Height: 4'11 (149.86 cm)
BM: last BM (01/31/20) medium soft well formed. Brown in color

Pain Assessment
□ Acute/Chronic □ Intensity ( 0-10)
□ Location
□ Duration
□ Characteristic
□ Precipitation
□ Frequency
□ Non-Verbals
□ Relief Factors
□ Sleep

Skin Assessment
□ Description _______________________
 HEALTH ASSESSMENT

Com
a
Patient's Name: (Last Name, First Name, Middle Name)
Birthday:
Hospital Registration #:
Religion:
Address:
Date of Admission:
Chief Complaint:
Admitting Diagnosis:

Other Diagnoses:

Allergies: (Food, Meds, Scents, Particles, Others)

Reaction to Allergies:

Contact in Case of Emergency :

Name:
Address:
CellPhone # / Landline #:
PICTURE
 Nurses' Notes
Date: Time:

Notes:

Date: Time:

Notes:
s
 VITAL SHEET
Date: Date: 01/31/2020 Date: (MM/ DD/ YY)
SHIFT: AM PM NIGHT PRN AM PM NIGHT
TIME TAKEN: 920
BP 124/38

TEMP (Degrees 36.8

Celsius)

AX
TEMP ROUTE
(Oral, Axillary,
PR, Forehead
Scan)
PR 102
RR 23
O2 SAT 98%

0/10
Pain Scale:
 VITAL SHEET
) Date: (MM/ DD/ YY) Date: (MM/ DD/ YY)
PRN AM PM NIGHT PRN AM PM NIGHT PRN
 I an
Date:
AM SHIFT
INPUT in ML OUTPUT in ML INPUT in ML

ROUTE AMOUNT ROUTE AMOUNT ROUTE

PO URINE 180ML PO

PNSS 1L
IVF AT 125ML BM IVF
DRAINAGE
PEG TUBE TUBES PEG TUBE

JT VOMITUS JT
NGT NGT
TPN TPN
MEDS MEDS
Others Others Others
Total INPUT 200 Total OUTPUT 0 Total INPUT

Others
Total OUTPUT 0
 I and O SHEET
PM SHIFT NIGHT SHIFT
INPUT in ML OUTPUT in ML INPUT in ML OUTPUT in ML

AMOUNT ROUTE AMOUNT ROUTE AMOUNT ROUTE

URINE PO URINE

BM IVF BM
DRAINAGE DRAINAGE
TUBES PEG TUBE TUBES

VOMITUS JT VOMITUS
NGT
TPN
MEDS
Others Others Others
Total INPUT 0 Total OUTPUT 0 Total INPUT 0 Total OUTPUT
SHIFT
OUTPUT in ML

AMOUNT

Total OUTPUT 0
Nursing Care Plan #1

(MM, DD,
Date Started: YYYY) Target Date: (MM, DD, YYYY)

Nursing Nursing Nursing

Cues/ Clues Diagnosis Objectives Interventions
 Nursing Care Plan #2

Date (MM, DD,

YYYY) Started: YYYY) Target Date: (MM/ DD/ YYYY)

Nursing Nursing Nursing

Evaluations Cues/ Clues Diagnosis Objectives Interventions Evaluations
Nursing Care Plan #3

(MM, DD,
Date Started: YYYY) Target Date: (MM/ DD/ YYYY)

Nursing Nursing Nursing

Cues/ Clues Diagnosis Objectives Interventions Evaluations
 HEALTH TEACHINGS
#1 Nursing Diagnosis:
Start Date:
End Date:

Health Teachings: 1)

#2 Nursing Diagnosis:
Start Date:
End Date:

Health Teachings: 1)
ALTH TEACHINGS
 Doctor's Progre
Date: Time:

Notes:

Date: Time:

Notes:
Doctor's Progress Notes