NOTE: Check to see if the template is still programmed in Cerner already 🙂
Ward:Â Â [ Assigned Nurse Unit ]
Room: [ Assigned Room ]
[ Language ]
Arrival: [ Arrival Date and Time ]
[ Hospitalist Code Status ]
Shift: NOC (1900-0700)
BRIEF SYNOPSIS:
RN ACUTE CONCERNS:
ICU IV Drips:
[ AC IV Rate Change ]
[ MU Medical Problems ]
ASSESSMENT
______________________________________________________________________
[ AC Vitals – Dyn Doc ]
NEURO: Aoxo4, moves all extremities, makes needs known, afebrile
RESP:
CARDIAC:
GI: [ Diet Order w/Supplements (ST) ]
Good appetite?
Swallows pills?
BG monitoring:
BM today?
Belly: soft & round?
Enteral access: NGT+ sm.bore FT (Coretrak)
GU:
Bladder scan:
SKIN/MS:
PAIN:
PSYCH:
CONSTITUTION:
______________________________________________________________________
[ AC Ventilator Monitoring ]
[ AC Arterial Blood Gases ]
[ INPT Last EKG Report ]
[ AC Fishbone Labs ]
[ AC Labs POC Glucose ]
[ Hospitalist Labs ]
[ AC Radiology Results ]
[ AC Drains & Tubes 24hr ]
IV Access:
Central Line?:
– last changed:
______________________________________________________________________
MICRO:
[ Document ED Micro Results ]
[ Microbiology Reuslts Completed Doc ]
Sepsis/SIRS Alert?
[ AC Antimicrobials ]
______________________________________________________________________
Input/Output:
[ INPT IO ST ]
[ AC Active Medications ]
PLAN
______________________________________________________________________
Team Treatment Plan:
[ * Diagnosis Related Orders ]
TREATMENT TEAM ASSESSMENT AND PLANS (Verbatim):
[ AC Consulting Physician ]
______________________________________________________________________
NURSING GOALS/PLANS for the Day
–
PT/OT Status:
Possible discharge or transfer?
Social Work/CM Status:
Stroke Protocol?
—
Report given to oncoming RN at shift change, who then assumed all patient care
*Please note: COVID Surge Charting may be in place