Gather necessary materials (pen, report sheet, etc.)
Prepare the necessary materials for the report sheet, including a pen, report sheet, etc.
Review the patient census for the shift
Review the patient census for the shift to get an overview of the number of patients.
Record physicians responsible for each patient
Note down the physicians responsible for each patient.
Jot down the current medical orders for the patients
Write down the current medical orders for each patient.
Write down relevant laboratory values
Document the relevant laboratory values for each patient.
Document the patient's current medications
Log the patient's current medications.
Log any allergies the patient has
Record any allergies the patient has.
Note the patient's dietary restrictions or requirements
Take note of the patient's dietary restrictions or requirements.
Dietary Restrictions/Requirements
Record the patient's physical assessment findings
Record the patient's physical assessment findings.
Physical Assessment Findings
Track any pending labs or diagnostics
Track any pending labs or diagnostics for each patient.
Note the patient's activity level and mobility status
Take note of the patient's activity level and mobility status.
Activity Level An option will be selected here
Mobility Status An option will be selected here
Bedridden
Assisted
Independent
Write down the patient's plan of care and goals for the shift
Record the patient's plan of care and goals for the shift.
Document any family or social issues to be aware of
Document any family or social issues to be aware of for each patient.
Jot down the patient's pain level or any other discomforts
Write down the patient's pain level or any other discomforts.
Pain Level An option will be selected here
No Pain
Mild
Moderate
Severe
Record the next scheduled rounds for the patient
Note down the next scheduled rounds for each patient.
Approval: Charge Nurse Review
Gather necessary materials (pen, report sheet, etc.)
Will be submitted
Review the patient census for the shift
Will be submitted
Write down the patient's basic information (name, age, diagnosis, etc.)
Will be submitted
Record physicians responsible for each patient
Will be submitted
Jot down the current medical orders for the patients
Will be submitted
Write down relevant laboratory values
Will be submitted
Document the patient's current medications
Will be submitted
Log any allergies the patient has
Will be submitted
Note the patient's dietary restrictions or requirements
Will be submitted
Record the patient's physical assessment findings
Will be submitted
Track any pending labs or diagnostics
Will be submitted
Note the patient's activity level and mobility status
Will be submitted
Write down the patient's plan of care and goals for the shift
Will be submitted
Document any family or social issues to be aware of
Will be submitted
Jot down the patient's pain level or any other discomforts
Will be submitted
Log any discharge planning information necessary
Will be submitted
Record the next scheduled rounds for the patient
Will be submitted
