Date: _________________________ Preceptor: ____________________________ Student Name: ______________________________

Rm# Name: Rm# Name: Rm# Name: Rm# Name:

Age: Allergies: Age: Allergies: Age: Allergies: Age: Allergies:

Doctor/Consults: Doctor/Consults: Doctor/Consults: Doctor/Consults:

Admitting date and diagnosis, events leading to Admitting date and diagnosis, events leading to Admitting date and diagnosis, events leading to Admitting date and diagnosis, events leading to
hospitalization, what has happened since hospitalization hospitalization, what has happened since hospitalization hospitalization, what has happened since hospitalization hospitalization, what has happened since hospitalization

Past Medical History: Past Medical History: Past Medical History: Past Medical History:

Diet: Accu: I/O: Diet: Accu: I/O: Diet: Accu: I/O: Diet: Accu: I/O:
AC &HS AC &HS AC &HS AC &HS
Other: Other: Other: Other:
Activity: Code Status: VS: Activity: Code Status: VS: Activity: Code Status: VS: Activity: Code Status: VS:

Resp Tx: Monitor: Wt: Resp Tx: Monitor: Wt: Resp Tx: Monitor: Wt: Resp Tx: Monitor: Wt:

O2 O2 O2 O2
IVs (solution, site, tbg, drsg, caps): IVs (solution, site, tbg, drsg, caps):: IVs (solution, site, tbg, drsg, caps):: IVs (solution, site, tbg, drsg, caps)::

Wound/Tube Care: Wound/Tube Care: Wound/Tube Care: Wound/Tube Care:

NG Foley CT JP Penrose Trach NG Foley CT JP Penrose Trach NG Foley CT JP Penrose Trach NG Foley CT JP Penrose Trach

Meds: Meds: Meds: Meds:

Report: Report: Report: Report:

Labs/Diagnostics/Procedures to be done this shift Labs/Diagnostics/Procedures to be done this shift Labs/Diagnostics/Procedures to be done this shift Labs/Diagnostics/Procedures to be done this shift
Room: Name: Room: Name: Room: Name: Room: Name:
Abnormal and pertinent normal assessment findings: Abnormal and pertinent normal assessment findings: Abnormal and pertinent normal assessment findings: Abnormal and pertinent normal assessment findings:
Neuro: Neuro: Neuro: Neuro:

Pulm: Pulm: Pulm: Pulm:

CV: Rhythm: CV: Rhythm: CV: Rhythm: CV: Rhythm:

Gi/Gu: Gi/Gu: Gi/Gu: Gi/Gu:

M/S: M/S: M/S: M/S:

Integ: Integ: Integ: Integ:

Pain Management: PCA: Pain Management: PCA: Pain Management: PCA: Pain Management: PCA:

Vital signs: Accucheck: Vital signs: Accucheck: Vital signs: Accucheck: Vital signs: Accucheck:

I/O: I/O: I/O: I/O:

Critical/Priority lab/diagnostic test results Critical/Priority lab/diagnostic test results Critical/Priority lab/diagnostic test results Critical/Priority lab/diagnostic test results

Other: Other: Other:

Other:

New Orders: New Orders: New Orders: New Orders:

Patient Education this shift / needs: Patient Education this shift / needs: Patient Education this shift / needs: Patient Education this shift / needs:

Discharge Plans: Discharge Plans: Discharge Plans: Discharge Plans:

Shift Goals Shift Goals Shift Goals Shift Goals