Medical Report Sheet
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1Room #: ________
Date: ______________
MRN: __________________
Weight: _______kg
Age: _____
Patient Name: _______________________________ Code Status: ___________
Allergies: _____________________
Isolation: ___________________ Date of Admission: _______________________________________________
Admit Dx: ___________________________________________________________________________________
PMHx: _____________________________________________________________________________________
_____________________________________________________________________________________
Labs:
Neuro:
WBC: _____ 4.5-11
A&Ox___
Eyes: ___________
Cough/Gag: _______
Restraints: ____________
Hgb:
_____ ♀12-16 ♂ 13-18
Pain Issues: ____________________ Meds Last Given: __________________
Hct:
_____ ♀36-46 ♂37-49
Sedation: ____________________________________
Neuro Checks Q ___hrs
Plts:
_____ 100-450
CV:
+
Na
:
_____ 135-145
Rhythm: ______ HR: ______ MAP: _____ Systolic: _______/Diastolic: _______
+
K
:
_____ 3.5-5.2
Pulses: UE ___/___, LE ___/___
Edema: UE ___/___, LE ___/___
T-Max: ______
-
Cl
:
_____ 95-107
Access: #1 ________ #2 ________ #3 ________ #4 ________ #5 ________ CVP: _____
Mg:
_____ 1.6-2.4
Phos
_____ 2.4-4.1
Resp:
+
Ca
:
_____ 8.8-10.3
Natural/#__ ETT/Shiley/Bivona
___
Teeth/Lip
O
: RA/NC/Mask/TC/Vent/BiPAP/CPAP
@
2
+
i Ca
:
_____ 2.24-2.46
Vent Settings: ________ FiO
: _____% Rate: _____ PEEP: _____ TV: _____
2
BUN:
_____ 7-20
Breath Sounds: _______/________ Secretions: _______________ Suction Q ___
Creat: _____ 0.5-1.4
Resp Rate: _____ SpO
: _____%
2
PT:
_____ 10-12
Chest Tube: R/L Water Seal/Suction Drainage: ____________ OP Last Shift: _____
PTT:
_____ 30-45
GI:
INR:
_____ 1-2
NPO
R/L NGT
OGT
PEG G-J
Keofeed
LIWS
PO Diet: __________________
ABG:
TF Type: __________ ml/hr: _____ H
O Boluses: ____mls Q ___hrs
Prosource: _____pkts
2
pH:
_____ 7.35-7.45
TPN: _____ml/hr
Lipids: _____ml/hr
pCO
: _____ 35-45
Rectal Bag/Rectal Tube/Flexiseal
2
pO
:
_____ 70-100
Fingersticks Q ___hrs/ACHS
2
HCO
: _____ 19-25
3
GU:
Foley/Texas Cath/Bedpan/Urinal/Bedside Commode/Diaper
Plan:
To Do:
Color: __________
+/- _______mL Last Shift
o Careplan
Dialysis: _______________________
o Morse Falls Risk/Restraint
o Education
Skin:
Drips:
o Restraint Order UTD
#1: ________________________________________
________________
#2: ________________________________________
______________________
o
#3: ________________________________________
________________
______________________
o
#4: ________________________________________
________________
______________________
Wound Care Consulted? Yes/No
o
________________
______________________
o
Social/Family:
________________
______________________
o
________________
______________________
o
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