NOC SHIFT RN REPORT
History and Physical-@MEMD@ ATT: @ATTPROV@ PCP: @PCP@
@NAME@ @AGE@(@BDAY@) @DEPTNME@ @RRHLOS@
MRN: @MRN@
SYNOPSIS
@NAME@ is a @AGE@ @SEX@ ***
Admitted for
@DIAG@
@PROB@
@PROBACTHOSP@
RN CONCERNS/UPDATES
NOC SHIFT RN REPORT
History and Physical-@MEMD@ ATT: @ATTPROV@ PCP: @PCP@
@NAME@ @AGE@(@BDAY@) @DEPTNME@ @RRHLOS@
MRN: @MRN@
SYNOPSIS
@NAME@ is a @AGE@ @SEX@ ***
Admitted for
@DIAG@
@PROB@
@PROBACTHOSP@
RN CONCERNS/UPDATES
• NEURO
1. Behavioral description:
2. Temperature:
3. Weakness/Exceptions/Aberrations:
4. FC/MAE/ROM?:
• CARDS
1. Majority rhythm:
2. Pertinent Meds
3. MAP Goal
1. PRNs
4. Blood Thinners?
• RESP
1. Vent Mode: AC/
1. Settings @FLOW(3330031802,301580,301570,7074344,7074327,301650,7074356,316060,316040,7074336,3463)@
2. Daily ABGs?
3. Secretions:
4. Home equipment?
• GI
1. @DIETORDERS@
1. H2O Flushes?
2. Route:
3. BG Checks?:
• GU
1. Foley y/n?
1. Indication:
2. Urine appearance:
3. 24 Hour I/O @IOBRIEF@
4. NOC Shift Net: m L
• SKIN
1. Intact?
2. Wounds:
1. New/old?
• PAIN
1. CPOT 0
2. Management:
• PROPHYLAXIS
1. Heparin subcutaneous
2. SCD
• LABS
1. Lytes repleted:
2. Serial collection?:
1. Daily CBC/CMP
3. Criticals:
4. Microbio:
• RESTRAINTS
1. Y/N:
2. Reason:
• MAIN PROBLEM TODAY
1.
• PT GOALS
1.
• PROVIDER PLANS
1.
2.
• OTHER
1. Family matters:
• PRECAUTIONS
1. Isolation
2. Inpatient
• CONSULTANTS
1. @CONORDS@
DRIPS
ICU DRIPS & CONTINUOUS IV’s
LINES:
- PIVs
@LINESANDTUBES@
VENT
VENT SETTINGS / ABGs
@VENTSETTINGS@
Arterial Blood Gas result:
pH ***;
pO2 ***;
pCO2 ***;
HCO3 ***,
%O2 Sat ***.
HISTORY/SOCIAL
@ALLERGY@
@PMH@
@PSH@
@FAMHX@
@FAMST@
@SOCHX@
@PTAMEDS@
VITALS
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
@LABBRIEFBMT(K,MG,CA,PHOS,NA,CREAT,IACO2,IAPH)@
Na @LABRESULT(NA)@ CL @LABRESULT(CL)@ BUN @LABRESULT(BUN)@ GLU
@LABRESULT(GLU)@
K @LABRESULT(K)@ CO2 @LABRESULT(BICARB)@ Cr @LABRESULT(CREAT)@
WBC @LABRESULT(WBC)@ HGB @LABRESULT(hgb)@ PLT @LABRESULT(PLT)@
HCT @LABRESULT(hct)@
PT @LABRESULT(PT)@ PTT @LABRESULT(PTT)@
INR @LABRESULT(INR)@
IMAGING
Imaging @ENCIMAGING@
Procedures @ENCPROC@
Other @ENCOTHERORDERS@
MEDS & ACTIVE ORDERS
See MAR
@ACTIVEORD@
@DCMED@
CARE 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@
DRIPS
ICU DRIPS & CONTINUOUS IV’s
LINES:
- PIVs
@LINESANDTUBES@
VENT
VENT SETTINGS / ABGs
@VENTSETTINGS@
Arterial Blood Gas result:
pH ***;
pO2 ***;
pCO2 ***;
HCO3 ***,
%O2 Sat ***.
HISTORY/SOCIAL
@ALLERGY@
@PMH@
@PSH@
@FAMHX@
@FAMST@
@SOCHX@
@PTAMEDS@
VITALS
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
@LABBRIEFBMT(K,MG,CA,PHOS,NA,CREAT,IACO2,IAPH)@
Na @LABRESULT(NA)@ CL @LABRESULT(CL)@ BUN @LABRESULT(BUN)@ GLU
@LABRESULT(GLU)@
K @LABRESULT(K)@ CO2 @LABRESULT(BICARB)@ Cr @LABRESULT(CREAT)@
WBC @LABRESULT(WBC)@ HGB @LABRESULT(hgb)@ PLT @LABRESULT(PLT)@
HCT @LABRESULT(hct)@
PT @LABRESULT(PT)@ PTT @LABRESULT(PTT)@
INR @LABRESULT(INR)@
IMAGING
Imaging @ENCIMAGING@
Procedures @ENCPROC@
Other @ENCOTHERORDERS@
MEDS & ACTIVE ORDERS
See MAR
@ACTIVEORD@
@DCMED@
CARE PLAN
NURSING PLAN OF THE DAY
NOC SHIFT RN REPORT
History and Physical-@MEMD@ ATT: @ATTPROV@ PCP: @PCP@
@NAME@ @AGE@(@BDAY@) @DEPTNME@ @RRHLOS@
MRN: @MRN@
SYNOPSIS
@NAME@ is a @AGE@ @SEX@ ***
Admitted for
@DIAG@
@PROB@
@PROBACTHOSP@
RN CONCERNS/UPDATES
• NEURO
1. Behavioral description:
2. Temperature:
3. Weakness/Exceptions/Aberrations:
4. FC/MAE/ROM?:
• CARDS
1. Majority rhythm:
2. Pertinent Meds
3. MAP Goal
1. PRNs
4. Blood Thinners?
• RESP
1. Vent Mode: AC/
1. Settings @FLOW(3330031802,301580,301570,7074344,7074327,301650,7074356,316060,316040,7074336,3463)@
2. Daily ABGs?
3. Secretions:
4. Home equipment?
• GI
1. @DIETORDERS@
1. H2O Flushes?
2. Route:
3. BG Checks?:
• GU
1. Foley y/n?
1. Indication:
2. Urine appearance:
3. 24 Hour I/O @IOBRIEF@
4. NOC Shift Net: m L
• SKIN
1. Intact?
2. Wounds:
1. New/old?
• PAIN
1. CPOT 0
2. Management:
• PROPHYLAXIS
1. Heparin subcutaneous
2. SCD
• LABS
1. Lytes repleted:
2. Serial collection?
1. Daily CBC/CMP
3. Criticals
• RESTRAINTS
1. Y/N:
2. Reason:
• MAIN PROBLEM TODAY
1.
• PT GOALS
1.
• PROVIDER PLANS
1.
2.
• OTHER
1. Family matters:
• PRECAUTIONS
1. Isolation
2. Inpatient
• CONSULTANTS
1. @CONORDS@
DRIPS
ICU DRIPS & CONTINUOUS IV’s
LINES:
- PIVs
@LINESANDTUBES@
VENT
VENT SETTINGS / ABGs
@VENTSETTINGS@
Arterial Blood Gas result:
pH ***;
pO2 ***;
pCO2 ***;
HCO3 ***,
%O2 Sat ***.
HISTORY/SOCIAL
@ALLERGY@
@PMH@
@PSH@
@FAMHX@
@FAMST@
@SOCHX@
@PTAMEDS@
VITALS
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
@LABBRIEFBMT(K,MG,CA,PHOS,NA,CREAT,IACO2,IAPH)@
Na @LABRESULT(NA)@ CL @LABRESULT(CL)@ BUN @LABRESULT(BUN)@ GLU
@LABRESULT(GLU)@
K @LABRESULT(K)@ CO2 @LABRESULT(BICARB)@ Cr @LABRESULT(CREAT)@
WBC @LABRESULT(WBC)@ HGB @LABRESULT(hgb)@ PLT @LABRESULT(PLT)@
HCT @LABRESULT(hct)@
PT @LABRESULT(PT)@ PTT @LABRESULT(PTT)@
INR @LABRESULT(INR)@
IMAGING
Imaging @ENCIMAGING@
Procedures @ENCPROC@
Other @ENCOTHERORDERS@
MEDS & ACTIVE ORDERS
See MAR
@ACTIVEORD@
@DCMED@
CARE 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@
Report given to oncoming RN, , at end of shift, who then assumed all care.
@MEMD@, BSN, CCRN
Electronic Signature
@TD@ @NOW@