BUKIDNON STATE UNIVERSITY

COLLEGE OF NURSING
MALAYBALAY CITY

Patient Monitoring Sheet

Patient: ___________________________________________________ Age: _____ Sex: ______ Date: ___________

Diagnosis: _________________________________________________ Diet: __________________________________

SPECIAL ENDORSEMENT DATE SAMPLE CHARTING

INTAKE AND OUTPUT

Shift Oral IVF Total Urine Other Total

IV FLUID/ BLOOD LINE / SIDE DRIP

Bottle No. /Name / Volume / Rate Level

VITAL SIGNS MONITORING

DATE TIME T P R BP FHT

NAME OF DRUG Timing

Example: Mefenamic Acid 500mg tab PO od bid tid qid q4 q6 q8 q12 prn stat

STUDENT NURSE: _______________________________ CLINICAL INSTRUCTOR: ___________________________________

NOTE: Please submit this form together with your PONR. One form per day!
Use lead pencil for sample charting.
NAME: __________________________ DATE: __________

C.I: _____________________________

GENERAL OBJECTIVES:

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SPECIFIC OBJECTIVES:

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PLAN OF ACTIVITIES:

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SCORE: _____________
NAME: ___________________________ DATE: _______________

C.I.: _____________________________

PROGRESS NOTES:

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SCORE: ______________
NAME: __________________________ DATE: __________

C.I: _____________________________

SPECIFIC OBJECTIVES:

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PLAN OF ACTIVITIES:

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SCORE: _____________
NAME: ___________________________ DATE: _______________

C.I.: _____________________________

PROGRESS NOTES:

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SCORE: ______________
NAME: ___________________________ DATE: _______________

C.I.: _____________________________

WEEKLY EVALUATION:

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SCORE: ________