Below Template Used Until 6/01/2024
NOC SHIFT RN REPORT
History and Physical-@MEMD@ ATT: @ATTPROV@ PCP: @PCP@
@NAME@ @AGE@(@BDAY@) @DEPTNME@ @RRHLOS@
MRN: @MRN@ Acct# @HARNUMID@
Admitted for
@CURRENTDIAGNOSIS@
BRIEF SYNOPSIS
CC: @CCNNOLINE@
@NAME@ is a @AGE@ @SEX@ ***
RN ASSESSMENTS/ CONCERNS/ UPDATES
- NEURO:
- CARDS:
- RESP:
a. Vent: Mode
i. @VENTSETTINGS@
b. Secretions: - GI:
a. @DIETORD@
i. H2O Flush:
b. BG q _ hrs - GU:
a. Foley:
i. Indication:
b. UOP: adequate, yellow/clr
c. IO:
i. @INTAKEOUTPUTBRIEF@ - SKIN: Intact
- PAIN: CPOT 0
- PROPHYLAXIS:
a. Heparin SC
b. Protonix - LABS:
a. Lytes Repleted: - GOALS:
- OTHER:
a. Family
CONSULTS
@CONORDS@
ICU DRIPS & CONTINUOUS IV’s
- Continuous Infusions:@MEDSINFUSIONS@
LINES:
– PIVs
VENT SETTINGS / ABGs
@VENTSETTINGS@
Arterial Blood Gases:
@LABRCNTIP(PHART:3,PCO2ART:3,PO2ART:3,HCO3ART:3,O2SATART,HCO3:3,O2SAT,THB,O2HB,CARBOXYHGB,METHB,HHB:3)@
Last ABG:
@LABLAST(PHART:3,PCO2ART:3,PO2ART:3,HCO3ART:3)@
@BRIEFLAB(PHART,PCO2ART,PO2ART,HGB,HBO2PER,CARBOXYHGB,HHB,HCO3ART,BEART,O2SATART,SAMPLETYPE,ROOM)@
HISTORY
@ALLERGY@
@PMH@
@PSH@
@FAMHX@
@FAMST@
@SOCHX@
@PTAMEDS@
VITALS
24 Hour Min / Max Current
@FLOWSTAT(6:24::1)@ @FLOW(6:last:1)@
@FLOWSTAT(5:24::1)@ @FLOW(5:last:1)@
@FLOWSTAT(8:24::1)@ @FLOW(8:last:1)@
@FLOWSTAT(9:24::1)@ @FLOW(9:last:1)@
@FLOWSTAT(10:24::1)@ @FLOW(10:last:1)@
Admit: @FLOW(14:first:1)@ @FLOW(14:last:1)@ @BMI@
LABS & RESULTS
@LABRECENT(WBC:2,HGB:2,HCT:2,PLT:2,NA:3,K:3,CL:3,CO2:3,BUN:3,CREATININE:3,GLUCOSE:3,CALCIUM:3,MG:3,PHOS:3,BILITOT:3,CONJBILI:3,AST:3,ALT:3,ALKPHOS:3,LIPASE:3,ALBUMIN:3,TOTALPROTEIN:3,APTT,LABPT,INR,CK,TROPONINT,TROPONINI,BNP,CHOL,TRIG,HDL,LDLDIRECT,TSH)@
@LABRECENT(COLORU:3,CLARITYU:3,SPECGRAVUR:3,PHUR:3,LEUKOCYTESUR:3,NITRITEU:3,PROTEINUA:3,GLUCOSEU:3,UROBILINOGEN:3,BILIRUBINUR:3,BLOODU:3,KETONESU:3,RBCUA:3,WBCUA:3,SQUAMEPIUA:3,BACTERIA:3)@
@LABRECENT(URINECX:3,Sputumcultur:3,BLOODCX:3)@
@RISRSLT2DAYSIMPRESSIONONLY@
@RESUFAST(PTT)@
@RESUFAST(INR:3,PROTIME:3)@
MEDS
Scheduled Meds:
@MEDSSCHEDULED@
PRN Meds:
.@MEDSPRN@
@DCMEDSLAST36HOURS@
INTERDISCIPLINARY TEAM PLAN
NURSING PLAN OF THE DAY
Maintenance Tasks
-add/maintain PIVs, check need for CVC/Foley
-monitor electrolytes
-strict I/o when ordered
-neuro checks periodically
-monitor HGB; check s/s bleeding
-ensure airway trach patency
-elevate arms, if app
-d/w attending pt status
-turned pt q2h
-fall risk observed
-wound care/prevention as necessary
Report given to oncoming RN at end of shift, who then assumed all care.
@MEMD@, BSN, CCRN
Electronic Signature
@TD@ @NOW@