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Sample Charting Montano

The document details the care provided to a patient named Luis over the course of a day. It includes vital sign checks, medical orders, intake and output tracking, treatments, and assessments by doctors and nurses.

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Karl Angelo Montano
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65 views1 page

Sample Charting Montano

The document details the care provided to a patient named Luis over the course of a day. It includes vital sign checks, medical orders, intake and output tracking, treatments, and assessments by doctors and nurses.

Uploaded by

Karl Angelo Montano
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Date Time Entry

10/12/2021 7-3 Received lying on bed, awake and, not in any forms of distress, dizziness
7am not noted,
With an IVF of D5IMB 1L 40cc/hr infusing well @ left metacarpal vein
8am Vs checked and recorded BP of 120/80 CR 70bpm PR 68bpm temp. 37c
RR 19cpm
Linens changed and stretched, patient placed comfortably
9am Health teachings rendered such as to:
Instructed to increase fluid intake and to have small frequent feeding if
vomiting occurs
Drink ORS every after watery stool
Instructed to have adequate rest and sleep
11am Seen and assessed by Doctor Hernandez with order made
For repeat stool exam
12 nn Vs rechecked and recorded BP of 120/80mmhg CR 74bpm PR 72bpm
temp. 37.3 RR 17cpm
Observed eating with good appetite, able to consume half meal
2pm Above IVF consumed and followed up with D5IMB 1L @ 40cc/hr. Above
IVF consumed and terminated.
I&O checked recorded
3pm Left on bed asleep with same IVF on.
Affix Signature
Karl Angelo Montano, St.N / Karl Gallardo, RN
STUDENT CI
Name: Luis, beam Ward:

Case: abdominal pain Room#: 401

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