Clinical Organization Sheet N126

Your Assessment

AM Report you need this information before caring for your patient

Vital Signs & Pain (note time):

Sensory System:

Labs:

Blood Sugars (time, results, coverage):

Respiratory/Oxygen:

Cardiovascular:

Gastrointestinal:

Genitourinary:

Skin, Hair, Nails:

Neurological/Psychological:

Musculoskeletal:

Hematological/Endocrine:

Student Name:
Patient Initials:

Age:

Rm:

Allergies:

Medical Diagnosis:
Additional Information (catheter, dressing, present, IV, etc):
Activity:

Code Status:

Diet:
Assistive Devices (wheelchair, walker, braces, etc):
Last Set Vital Sign Results & Frequency:
T
R
O2 saturation
P
BP
Oxygen Treatment:

Report Off Communication to Your Nurse:

Medications times:
*Use medication organization sheet for full information
Pain Status/Management (include last time medication received):
I &O, Mental Status/Level of Consciousness:
Plan of care for day:

Vital Signs (time and results)

Key Assessment Info (problem focused assessment)
Patient needs/concerns
Pain
Medication Issues
Care provided
I&O
Blood Sugars (time/results/coverage)
*Remember to follow a logical, consistent order; give exact information
including times; ask if there are any further questions.