Scribd
Upload
2K views1 page

Clinical Organization Sheet Nursing

This clinical organization sheet provides information to assess and care for a patient on an AM nursing shift. It includes the patient's vital signs, pain level, lab results, respiratory status, skin condition, neurological assessment, and mobility. The patient's age, allergies, medical diagnosis, and code status are noted. The nurse is asked to communicate the patient's medications, pain management, intake and output, and mental status to the oncoming nurse, as well as the care plan for the day.

Uploaded by

Sarah S
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
2K views1 page

Clinical Organization Sheet Nursing

This clinical organization sheet provides information to assess and care for a patient on an AM nursing shift. It includes the patient's vital signs, pain level, lab results, respiratory status, skin condition, neurological assessment, and mobility. The patient's age, allergies, medical diagnosis, and code status are noted. The nurse is asked to communicate the patient's medications, pain management, intake and output, and mental status to the oncoming nurse, as well as the care plan for the day.

Uploaded by

Sarah S
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
  • Clinical Organization Sheet

Clinical Organization Sheet N126

Your Assessment

AM Report you need this information before caring for your patient

Vital Signs & Pain (note time):

Sensory System:

Labs:

Blood Sugars (time, results, coverage):

Respiratory/Oxygen:

Cardiovascular:

Gastrointestinal:

Genitourinary:

Skin, Hair, Nails:

Neurological/Psychological:

Musculoskeletal:

Hematological/Endocrine:

Student Name:
Patient Initials:

Age:

Rm:

Allergies:

Medical Diagnosis:
Additional Information (catheter, dressing, present, IV, etc):
Activity:

Code Status:

Diet:
Assistive Devices (wheelchair, walker, braces, etc):
Last Set Vital Sign Results & Frequency:
T
R
O2 saturation
P
BP
Oxygen Treatment:

Report Off Communication to Your Nurse:


Medications times:
*Use medication organization sheet for full information
Pain Status/Management (include last time medication received):
I &O, Mental Status/Level of Consciousness:
Plan of care for day:

Vital Signs (time and results)


Key Assessment Info (problem focused assessment)
Patient needs/concerns
Pain
Medication Issues
Care provided
I&O
Blood Sugars (time/results/coverage)
*Remember to follow a logical, consistent order; give exact information
including times; ask if there are any further questions.

You might also like