REGISTRATION SHEET
Patient's Name: (Last Name, First Name, Middle Name)
Birthday:
Hospital Registration #:
Religion:
Address: 123
Date of Admission:
Chief Complaint:
Admitting Diagnosis:
Other Diagnoses:
Height / Body Weight/ BMI
Allergies: (Food, Meds, Scents, Particles, Others)
Reaction to Allergies:
Contact in Case of Emergency : FATHER
Name:
Address: 123
CellPhone # / Landline #:
Advance Directive/ Type:
Instructions:
1.) Create your own hypothetical data
2.) All entries should be labeled properly
Picture
EGISTRATION SHEET
MONTELFACO, AMARAH SANTOS
20-May-00
81100
Roman Catholic
123 Green St. Brgy. Pinatubo, Laguna City
18-Feb-24
Macular rash 24-48 hrs
Chicken Pox
None
160cm/ 48kg/ 17.75 (Underweight)
None
None
Montefalco, Brian J.
123 Green St. Brgy. Pinatubo, Laguna City
99668540324
PICTURE
This is a general checklist of what the unit/ ward nurse is supposed to accomplish within the EMR within t
Directions: The system will write " YES" if DONE and "X" if NOT DONE
Date: (02/18/2024)
AM PM NIGHT
VS YES YES YES
I/Os YES YES YES
MAR YES YES YES
NCP YES YES YES
Monitoring YES YES YES
Q Shift Head to Toe Assessment YES YES YES
Fall Assessment YES YES YES
Skin Assessment YES YES YES
Health Teachings YES YES X
Laboratory Results Checking YES YES YES
Discharge Planning X X X
Instructions:
1. Do 1 whole day of Checklist
2. Place Yes in AM, PM, Night shift for VS, I/O, MAR, NCP, Monitoring, Q shift Head to Toe Assessment, Fal
3. Place Yes in AM, PM shift for Health Teaching, Place X for Night shift for Health Teaching
4. Place X in AM, PM, Night shift for Discharge Planning
5. Place a date on the 1 day in the checklist that you accomplished
plish within the EMR within the shift.
"X" if NOT DONE
DAILY CHECKLIST
Date: (02/19/2024) Date:(02/20/2024)
AM PM NIGHT AM
YES YES YES YES
YES YES YES YES
YES YES YES YES
YES YES YES YES
YES YES YES YES
YES YES YES YES
YES YES YES YES
YES YES YES YES
YES YES YES YES
YES YES YES YES
X X X X
Head to Toe Assessment, Fall Assessment, Skin Assessment, Laboratory Results Checking)
alth Teaching
02/20/2024)
PM NIGHT
YES YES
YES YES
YES YES
YES YES
YES YES
YES YES
YES YES
YES YES
YES YES
YES YES
YES YES
Date: Date: 02/18/24
SHIFT: AM
TIME TAKEN: 0400h
BP 120/80mmhg
TEMP (Degrees Celsius) 37.5 ºC
TEMP ROUTE (Oral, Axillary, PR, Forehead Scan) Axillary
PR 70
RR 20
O2 SAT 98%
Pain Scale: n/a
Pain Scale Used: n/a
Instructions:
1. Indicate a vital signs for 1 day (AM, PM, Night) shift
2. Complete all parts for 1 whole day (3 shifts)
3. Place a date
VITAL SHEET
02/18/24 Date: MM/DD/YR
AM PM PM NIGHT NIGHT AM
0800h 1200h 1600h 2000h 0000h 0400h
130/90mmhg 120/90mmhg 110/90mmhg 120/80mmhg 120/90mmhg
37 ºC 38 ºC 36.5 ºC 36.5 ºc 37 ºC
Axillary Axillary Axillary Axillary Axillary
63 80 72 76 79
22 23 19 18 22
98% 95% 96% 99% 95%
n/a n/a n/a n/a n/a
n/a n/a n/a n/a n/a
MM/DD/YR
AM PM PM NIGHT NIGHT
0800h 1200h 1600h 2000h 0000h
Date: 02/18/24
AM SHIFT
INPUT in ML OUTPUT in ML
ROUTE AMOUNT ROUTE
PO 750ml URINE
IVF 500ml BM
PEG TUBE 0 DRAINAGE TUBES
JT 0 VOMITUS
NGT 0
TPN 0
MEDS 0
Others 0 Others
Total INPUT 0 Total OUTPUT
Intake and Output Balance
Intake Output Balance
AM Shift 0 0 0
PM Shift 0 0 0
Night Shift 0 0 0
Instructions:
1.) Key in / Type the following:
> AM Intake: Per Orem 750ml, IVF: 500 ml
> AM output: Urine output: 630 ml, Jackson Pratt (Drainage tube: 120 ml), Vomitus: 100
> PM Intake: Per Orem: 500ml, IVF: 850 ml, NGT: 100 ml
> PM Output: Urine Output: 500 ml, Jackson Pratt (Drainage tube) 60 ml)
> Night Intake: NGT: 100ml, Per Orem: 200 ml
> Night Output: Urine output: 200 ml, Jackson Pratt (Drainage Tube: 50 ml)
2.) If there are no values indicated in #1 (Place Zero)
3.) Place a date
I and O SHEET
PM SHIFT
OUTPUT in ML INPUT in ML
AMOUNT ROUTE AMOUNT
630ml PO 500ml
400ml (watery) IVF 850ml
120ml PEG TUBE 0
100ml JT 0
NGT 100ml
TPN 0
MEDS 0
0 Others 0
Total OUTPUT 0 Total INPUT 0
t (Drainage tube: 120 ml), Vomitus: 100 ml, Bowel Movement: 400 ml (watery)
att (Drainage tube) 60 ml)
ratt (Drainage Tube: 50 ml)
and O SHEET
PM SHIFT NIGHT SHIFT
OUTPUT in ML INPUT in ML
ROUTE AMOUNT ROUTE AMOUNT
URINE 500ml PO 200ml
BM 0 IVF 0
DRAINAGE TUBES 60ml PEG TUBE 0
VOMITUS 0 JT 0
NGT 100ml
TPN 0
MEDS 0
Others 0 Others 0
Total OUTPUT 0 Total INPUT 0
NIGHT SHIFT
OUTPUT in ML
ROUTE AMOUNT
URINE 200ml
BM 0
DRAINAGE TUBES 50ml
VOMITUS 0
Others 0
Total OUTPUT 0
H
#1 Nursing Diagnosis: Chicken Pox
Admission date: 02/18/24
HEALTH TEACHINGS: 1) Keep fingernails trimmed short and minimize scratching to prevent the virus from sp
Avoid anything acidic or salty, like orange juice or pretzels. 4) If itchiness occur, pat the area not rub.
INSTRUCTION:
1. Identify a nursing diagnosis
2. Give 4 health teachings appropriate to the nursing diagnosis given
HEALTH TEACHINGS
ng to prevent the virus from spreading to others and to help prevent skin infections. 2) Calamine lotion may help relieve some of the itchin
r, pat the area not rub.
help relieve some of the itching. 3) Give cold, soft, bland foods.
Directions: Change the administration box (yellow) to actions taken (see legend colors)
LEGEND: GIVEN DELAYED
NOT GIVEN DISCONTINUED
MEDICATIONS
Ciprobay (ciprofloxacin) 500mg PO one tab every 12 hrs for 7 days
Start Date : Jan. 24, 2020 End Date: Feb. 3, 2020
Revicon one tab PO daily
Start Date: Feb. 01,2020 End Date: NONE
Losargard (losartan) 50mg PO Once a day
Start Date: Feb. 01, 2020 End Date: May 31, 2020
Instructions:
1. Ciprofloxacin (Ciprobay) was given on Feb 1 @ 1000h and Feb 1 @2200h, Feb 2 the 1000h dose was delay
2. Revicon was given as ordered
3. Losartan is given at 0800h was given on Feb 1, 2020, Losartan was not given on Feb 2, 2020 due to low bl
end colors)
MEDICATION ADMINISTRATION RECORD (MAR)
Feb. 01, 2020 Feb. 02, 2020 Feb. 03, 2020
TIME ADM TIME ADM TIME
1000h 1000h 1000h
2200h 2200h 2200h
0800h 0800h 0800h
0800h 0800h 0800h
eb 2 the 1000h dose was delayed due to to a procedure, Feb 2, 2200h dose was given in time, Feb 3, 2020 1000h dose was given, Feb 3, 20
n on Feb 2, 2020 due to low blood pressure, Feb 3, 2020 the dose was given as scheduled
MAR)
Feb. 03, 2020
ADM
000h dose was given, Feb 3, 2020, 2200h dose was discontinued
