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 Emergency Nursing
Affix patient label
MOUNT SINAI HOSPITAL Affix Patient Label Care Record
Time
Emergency Nursing Care Record Progress notes
(HH:MM)

Joseph and Wall Lebovic Health Complex

Emergency Depertement
600 University Avenue
Toronto, Ostario, Canada M5G TKS
Form MS 560 TRIAL (Rev 10.2010)

Date : Time :
YYYY MM DD HH .
MM

Room :
Presenting Health Problem Health History/Allergies
Smoker Yes No

Brought in by police: Badge # Security arrived to bedside: Time :

HH . MM
 Time
Heart Rate

Cardiac Rythm

Blood Pressure

Respiratory Rate

SpO2

Oxygen LPM %

Temperature
Pain
eyes

Verbal
Motor
Glasglow Coma
Scle
+/- CAM
mm
Size
L

t
+/-
Reac
Pupils

mm
Size
R

t +/-
Reac
R
Arm

L
Strength

R
Leg

L
Initials
 Pupills (size in mm)
1 2 3 4 Eyes
4 =
Spontaneous
5 6 7 8 3 = To voice
2 = To pain
1 = None
S = Swollen
Shut
Verbal Motor
Strength

5 = Oriented 6 = Obeys commands

N = Normal

4 = Disorionted 5 = Localizes pain

W = Weak

3 = Inappropiate words 4 = Withdraw pain

A = Absent

2 = Incomprehensible sounds 3 = Flex to pain

1 = None 2 = Extend to pain

T = ET Tube/Trach 1 = None
 Transfer Summary

Date (YYY.MM.OO) Time (HH.MM) U Report given by Report given to

n
i
t
Discharge Summary
Date (YYY.MM.OO) Time (HH.MM) Accomparied by

Follow-up Plan :

Written Intructions :

Health Teaching :

Discharge Nurse :
 Interventions CBGM

Time Intravenous Gauge Intravenous Initials Time Value Initial

(HH,M Initiation Location (HH,MM)
M)
Site #1

Site #2

Site #3

Site #4

Time Interventions Size Site/Comments/D Initials

(HH,M rainage
M)
Urinary Catheter

Gastric Tube

Central Line

Artherial Line
 Intravenous Intake

Time Site # Bag # Solution Volume Rate End Time Initials Time Intake Output Initials
(HH,MM) (HH,MM) (HH,MM)
 Medications

Time Medication Dose Route Initials Time Effect Initials

(HH,MM) (HH,MM)
 HEALTH ASSESSMENT FORMAT
Nursing History and Physical Examination
Date :
Place :

History :
Biographic and/or demographic details
Name :
Age :
Sex : M/F
Address :
Permanent :
Present :
Hospital Registration No :
Date of admission :
Ward and unit :
Bed No :
Marital status :
Religion :
Language :
Educational qualifications :
Occupation :
Name of the attendant/famly members:
Age :
Relationship with the client :
Addres :
1.Details of previous hospitalization :

1.Allergies :

1.Menstruation
a.Age at menarchy
b.Regular/irregular
c.LMP
d.Menopause

1.Details of immunization :

1.Personal habits :

2.Current medication being taken :

3.Sleeping pattern (regular/irregular/any sleep disorder) :
4.Any fitness/exercise pettern :
5.Dietary details : Vegetarian/Nonvegetarian/Egg-vegetarian/Special diet
6.Job/ work detail : Any shifts/sitting or standing
Family History (make a family tree in the space provided an write the details)
History of any chronic illines : (DM, HTN, CAD, any other) :
History of any communicable disease in the family :
Birth/death in family :

Enviromental history
Drinking water supply :
Environmental sanitation :
Waste/exercise disposal :
Presence of files/mosquitoes/rodents :

Pysichosocial history
Language :
Detail of milestones development :
Social support evailable or not :
 SYSTEMIC PHYSICAL EXAMINATION

A. Head
Headache : Convulsions/seizures :
Injury :

B. Eyes
Glasses/contac lens : Blurred vision :
Pain : Inflammation :
Watering/discharge :

C. Ears
Hearing impairment : Hearing aid :
Pain : Discharge :
Tinnitus : Vertigo :
Surgery :

D. Nose
Discharge : URI :
Polyp : Epistaxis :
Allergies : Sinusitis :
Surgery :
A. Throat and mouth

Dysphagia : Bleeding :

Dental caries : Lesions :

Halitosis : Speech disorder :

Pain : Flourosis :

Oral hygiene :

A. Respiratory

Cough : Sputum :
Dyspnea : Dyspnea on exertion :
Activity intolerance : Hemoplysis :
Surgery :
A. Circulation
Pain : Palpitation :
Edema : Numbness :
Change in color : Syncope
Dizziness : Paroxysmal nocturnal
dyspnea :
Dyspnea : Postural hypotension :
A. Nutritional
Appetite : Nausea :
Vomiting : Dysphagia :
Indigestion : Weight change
Lost/gained :
Regurgitation :
Elimination: Normal bowel/bladder pattern
Constipation : Diarrhea :
Incontinence : Infection :
Melena : Hematuria :
Any surgery : Presence of catheter :

Reproductive
No of pregnancy : No of live issues :
Bleeding : Vaginal discharge :
Infection : Pain :
Nocturnal emission : Abortion :
Any surgery :
Neurological
Confusion Convulsions :
Weakness Loss of strength :
Paralysis Change in sensation :
Incoordination Headache :
Tingling/Pricking Pain :
Memory Numbness :
Consciousness Reflexes
(specify weak reflexes) :

Musculoskeletal system
Pain : Joint stiffness/Swelling :
Joint movement : Muscle strength :
Posture : Gait :
Weakness : Changes in ADL :
Skin
Rashes : Lesions :
Pallor : Texture :
Temperature : Color :
Nevi pigmentation : Dryness :

Endocrinal
Any hormonal problem (Please specify):

Hepatic system
Scleral yellowing : Urinary yellowing :
Skin color : Substance abuse :
 Nursing Care Plan-1

Clinical Speciality :

Identification Data:

Name : Diagnosis :

Age : Date of admission :

Sex : Date of planning :

Hosp Regn No :

Physician :

Ward :

Bed No :

Physician Orders (Latest Revised) :

Special Orders (Diet/Special Procedures) :

 Nursing management
Date Assessment Nursing Goals
Diagnosis
LTG :
STG :
 Nursing Management
Interventions Outcome Status of Objectives
Achieved/ Reassessed
Day Date Vital Signs Medication Injection Special IV Nursing Sign
T P R BP Orders Fluid Remarks
s
I
II

III
IV