| RM/Name/Age/Sex | Info to include | 246/S. Smith/65/F | Allergies | PCN |
PMH |
Any PERTINENT PMH – you don’t have room to write everything nor do you need to |
DM, HLD, HTN, CKD 3 |
Doc | Med a |
| CC | Why are they here? | DKA or SOB x 2 days – ED – BiPAP – ICU | CODE | FC |
| Hosp Course | Pertinent Events | 1/24: admit – DKA 1/25: Resp. Distress/Intubated 1/26: AF – DCCV x 1 |
Lines/Tubes (if you have a swan make sure to note cm marking – “swan @ 50cm)” |
RIJ x 3 (triple lumen) LFA # 20 RW # 22 CT x 2 (Med) LFA JP |
| NEURO | Int/Sed/GCS/PupilsRASS/SAT/ SBT/Tmax |
Int/Sed. GCS 5/2- sluggish/-3 FC, MAE on SAT, tachypenic on SBT, 39.7 |
GTTS Name & Rate |
Ins @ 2.1 D51/2NS20K @ 150 Prop @ 20 Fent @ 50 Amio @ 0.5 |
| RESP | ETT (size @ cm),Vent Settings/O2 settings, breathing tx, secretions | 7.5 @ 22 teeth 50%/8/16/380 Q 4 nebs, thick, tan sec |
LABS:This is how I write my labs out (even as NP) then I just write Lactic or SvO2 or anything else | |
| CV | Rhythm/Rate BP MAP Goal Pulses/Edema |
NSR 80 1teens/70’s > 65 2+/2+ |
 |
|
| GI | Feeding Tube/inch mark/TF type, current rate, goal, last BM | NGT @ 65/Vital @ 20cc – goal 50, ↑ 10cc q 4 BM: 1/26/25 |
TO DO: Labs/Drsg △’s/Tubing △ |
BMP: 1200 △ prop @ 1400 △ Sacral mepilex 1600 |
| GU | Foley, condom Cath (CC), purewick ~ UOP/hr |
Foley – 45cc/hr | ||
| MSK | Pressure Injuries? Deformities? Amputations? |
Sacral DTI L BKA |
MISC/Round ORders/?’s | Add Prosource to TF Chest IPV D/C Foley – Purewick Plan if BP drops? (Gtt or IVF preferred?) |
This is an example of the information I included on my report sheet. I folded a blank sheet in 1/2 lengthwise where 1 outside and 1 inside was 1 patient. On the outside I wrote the report I received & questions for rounds and on the inside I wrote interventions during the day, I&O’s, CT drainage, etc. I only wrote what’s in italics to save space. I preferred this over the premade ones because I could include only what I wanted.