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    To Be Printed Corpuz Hospi Case Scenario 1

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    Cezanne Cruz
    This document contains forms and charts used to record a patient's medical information during a hospital stay. It includes sections to document the patient's personal details, medical history, vital signs, intake and output, medications, procedures, progress notes, and nursing notes. The forms are used to comprehensively monitor the patient's condition and treatment over time.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    To Be Printed Corpuz Hospi Case Scenario 1

    Uploaded by

    Cezanne Cruz
    123 views10 pages
    This document contains forms and charts used to record a patient's medical information during a hospital stay. It includes sections to document the patient's personal details, medical history, vital signs, intake and output, medications, procedures, progress notes, and nursing notes. The forms are used to comprehensively monitor the patient's condition and treatment over time.

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    Original Title

    -TO-BE-PRINTED-CORPUZ-HOSPI-CASE-SCENARIO-1

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    This document contains forms and charts used to record a patient's medical information during a hospital stay. It includes sections to document the patient's personal details, medical history, vital signs, intake and output, medications, procedures, progress notes, and nursing notes. The forms are used to comprehensively monitor the patient's condition and treatment over time.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    123 views10 pages

    To Be Printed Corpuz Hospi Case Scenario 1

    Uploaded by

    Cezanne Cruz
    This document contains forms and charts used to record a patient's medical information during a hospital stay. It includes sections to document the patient's personal details, medical history, vital signs, intake and output, medications, procedures, progress notes, and nursing notes. The forms are used to comprehensively monitor the patient's condition and treatment over time.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 10

    KARDEX

    NAME: ________________________________________________ AGE:______ SEX:_______ HOSPITAL NO._ _ ____


    ADDRESS:_______________________________________________________ CLASSIFICATION:___________ WEIGHT:________
    ADMITTING PHYSICIAN:_________________________________ DATE/TIME ADMITTED:_________________BLOOD TYPE:_____
    ATTENDING PHYSCIAN:______________________________________________________________________________________
    COMPLAINT:_______________________________________________________________________________________________
    IMPRESSION DIAGNOSIS:_____________________________________________________________________________________
    SURGERY DONE:________________________________________________________ DATE/TIME OF SURGERY_______________

    MENTAL STATUS: Activities: Diet: Tubes: Special Info:


    ___Conscious ___Ambulant ___NPO ___Foley Catheter ___Weigh Daily
    ___Drowsy ___Dangle and sit up ___DAT ___thoracic tube ___BP q shift
    ___Stupor ___Bedrest with BRP ___Soft ___NGT ___Neuro V/S
    ___Unconscious ___CBR w/o BRP ___Clear liquids ___CVP ___abdominal girth
    ___Comatose Others:___________ ___ Gen. liquids Others:__________ Others:___________
    _________________ Others:_____________ ________________ _________________

    Date Medication Date IV FLUIDS/ BLOOD TRANSFUSION DATE AND TIME


    ordered Ordered DISCONTINUED

    Date Medical Treatment/ Date Done


    Ordered Laboratories/Diagnostics
    INTAKE & OUTPUT MONITORING SHEET

    SURNAME:______________________M.I.:________ AGE:________ HOSPITAL NO.:_______________


    GIVEN NAME:_____________________________SEX:________ WARD/ROOM NO.:______________
    INTAKE OUTPUT
    Date Time Shift IVF Oral/NGT TOTAL Urine Drain TOTAL
    VITAL SIGNS MONITORING SHEET
    SURNAME: ______________________________________M.I.:______ AGE:______HOSPITAL NO.:________________
    GIVEN NAME: _________________________________________SEX:_______ WARD/ROOM NO.:_______________

    Date Time Shift BP PR RR Temp. REMARKS


    GRAPHIC RECORD

    SURNAME: ______________________________________M.I.:______ AGE:______HOSPITAL NO.:________________


    GIVEN NAME: _________________________________________SEX:_______ WARD/ROOM NO.:_______________

    DATE
    No. of Days in
    Hospital
    R 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7
    PR T
    R 9 1 5 9 1 5 9 1 5 9 1 5 9 1 5 9 1 5 9 1 5 9 1 5

    42

    41

    160 40

    150 39

    140 38

    130 37

    120 36

    110 35

    100

    90

    50 80

    40 70

    30 60

    20 50

    10

    Blood Pressure
    7-3
    3-11
    URINE
    11-7
    7-3
    3-11
    STOOL
    11-7
    IV FLUID SHEET
    SURNAME: ______________________________________M.I.:______ AGE:______HOSPITAL NO.:________________
    GIVEN NAME: _________________________________________SEX:_______ WARD/ROOM NO.:_______________

    MAIN LINE
    Time Time
    Date IV Fluids Regulation REMARKS
    Started Consumed

    ANOTHER LINE / SIDE DRIP


    Time Time
    Date IV Fluids Regulation REMARKS
    Started Consumed
    THERAPEUTIC SHEET

    SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________


    GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________

    Name of Drug, Dosage, Route, & Date and Time Given


    Frequency
    PHYSICIAN’S ORDER/PROGRESS NOTES

    SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________


    GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________
    TIME POSTED
    Date Progress Notes Doctor’s Order C A R E D AND
    SIGNATURE

    11-25-
    2020
    C- Carried A- Administered R- Requested E- Endorsed D- Discontinued
    NURSE’S NOTES
    SURNAME: ______________________________________M.I.:______ AGE:______HOSPITAL NO.:________________
    GIVEN NAME: _________________________________________SEX:_______ WARD/ROOM NO.:_______________

    Date-Shift FOCUS Data – Action – Response

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