ST.
MICHAEL’S COLLEGE
COLEGE OF NURSING
ENDORSEMENT FORM
Date: Shift: Total Census: Discharge:
Area: CI : Admission: Total Latest census:
VITAL SIGNS
NAME/ CC / AP IVF SPECIAL ENDORSEMENT MORNING AFTERNOON NOC
8AM 12NN 4PM 8PM 12AM 4AM
T T T T T T
P P P P P P
R R R R R R
BP BP BP BP BP BP
I I I
U U U
S S S
T T T T T T
P P P P P P
R R R R R R
BP BP BP BP BP BP
I I I
U U U
S S S
T T T T T T
P P P P P P
R R R R R R
BP BP BP BP BP BP
I I I
U U U
S S S
_______________________________ __________________________________ ____________________________________
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED
NAME
HEAD NURSING STUDENT CLINICAL INSTRUCTOR
CHARGE NURSE OF MCH
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
DAILY PLAN OF ACTIVIES & time inventory
DATE/ SHIFT:__________________________
AREA:________________________________
DATE/TIM PLAN OF ACTIVIES DATE/ INVENTORY OF ACTIVIES
E TIME
_________________________________________ _________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL
INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
ADMITTING DX: NURSES NOTES ADMITTING DX:
DATE/TIME/S NURSES NOTES/ NAME OF PT. DATE/TIME/S NURSES NOTES/ NAME OF PT.
HIFT HIFT
_________________________________________ _________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL
INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
PATIENT ASSIGNMENT AND CENSUS
RM # NAME OF ADMITTING DX ASSIGNED RM # NAME OF ADMITTING DX ASSIGNED
PATIENT STUDENT PATIENT STUDENT
Date: Shift: Total Census: Discharge:
Area: CI : Admission: Total Latest census:
______________________________________ __________________________________ ____________________________________
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED
NAME
HEAD NURSING STUDENT CLINICAL INSTRUCTOR CHARGE NURSE OF MCH
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
Medication checklist
Date: Shift: Total Census: Discharge:
Area: CI : Admission: Total Latest census:
RM# NAME OF PATIENT NAME OF DRUGS TIME ROUTE OF NAME OF MCH SIGNATURE OF MCH
GIVEN ADMINISTRATION STAFF STAFF
______________________________________ __________________________________ ____________________________________
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED
NAME
STAFF NURSING STUDENT CLINICAL INSTRUCTOR CHARGE NURSE OF MCH
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
VITAL SIGNS SHEET
DATE/ SHIFT:__________________________ AREA:________________________________
PATIENT’S NAME ROO TIME TIME I/O U/S STUDENT NURSE
M # ASSIGNED
T P R BP T P R BP
Prepared by:__________________________ Noted by: ___________________________ Supervised
by:____________________________
TEAM LEADER CHARGE NURSE CLINICAL
INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
Nurse’s daily evaluation
DATE/ SHIFT:__________________________ AREA:________________________________
WHAT DID I LEARN
TODAY
WHAT HINDERS MY
LEARNING
WHAT IS/ARE MY
MEMORABLE EVENTS I
HAD TODAY
WHAT I WANT TO LEARN
TOMORROW
MY PRAYER FOR TODAY
IS….
________________________________________ _________________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
IV MONITORING SHEET
DATE/ SHIFT:__________________________ AREA:________________________________
IVF Stock on
Level Time
STUDENT NURSE IVF Bottl Rat IV Time Cabinet
ROOM Left
#
PATIENT’S NAME ASSIGNED vol e # e
consume
TF
followe
d d up Receive
(ml) Endorse
d d
Prepared by:__________________________ Noted by: ___________________________ Supervised
by:____________________________
TEAM LEADER CHARGE NURSE CLINICAL
INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
DIAGNOSTIC/LABORATORY STUDIES SHEET
DATE/ SHIFT:__________________________ AREA:________________________________
DATE
NAME OF INDICATION NORMAL ACTUAL SIGNIFICANCE OF THE
DONE
TEST/PROCEDURE VALUE RESULTS/FINDIN RESULTS/FINDINGS
GS
________________________________________ ________________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL
INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
SUPERVISED SUPERVISION
DATE/ SHIFT:__________________________ AREA:________________________________
NAME OF NAME OF PATIENT DATE SUPERVISED BY REMARKS
PROCEDURE PERFORMED
Prepared by: Supervised by: Noted by:
________________________________________ ____________________________________ ___________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT TEAM LEADER
CLINICAL INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
HEALTH TEACHING PLAN(WARD CLASS)
DATE/ SHIFT:__________________________ AREA:________________________________
GOAL:
LEARNING TIME
LEARNING
LEARNING OBJECTIVES LEARNING ACTIVITIES LEARNING OUTCOME
CONTENT ALLOTMENT
Prepared by:__________________________ Noted by: ___________________________ Supervised
by:____________________________
TEAM LEADER CHARGE NURSE CLINICAL
INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
General/specific objectives
DATE/ SHIFT:__________________________ AREA:________________________________
GENERAL OBJECTIVES:
SPECIFIC OBJECTIVES:
________________________________________ ________________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
Requirements & attendance form
DATE/ SHIFT:_________________________
AREA:________________________________
Requirements Attendance Remarks
Pr CS/
STUDENT NURSE SO DPA/TIS NDE Notes P
N DP K SS DRS 1 2 3
oj P
GO C D/L
A P
1 2 3 1 2 3 1 2 3 1 2 3 1 2 1 2 3
Prepared by:__________________________ Supervised
by:____________________________
TEAM LEADER CLINICAL INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
Digital reading summary
DATE/ SHIFT:__________________________ AREA:________________________________
SUMMARY:
REACTION:
________________________________________ ________________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
Discharge plan worksheet
DATE/ SHIFT:__________________________ AREA:________________________________
A. DISCHARGE PLAN GIVEN TO: Patient Family Significant Others Destination: Home
Transfer Others
Date Instruction Given: ____________________ Given by: __________________________________________
B. DIET: Regular Special Specify:_________________________________
Special Instruction: __________________________________________________________________________________________________________________________________
C. INFORM PHYSICIAN for any observable signs/symptions of exacerbation or complication
Condition: _________________ S/Sx: ____________________________ Complication: ______________
S/Sx:_____________________________________
Name of Physician: ____________________________ Address: ________________________________ Contact Numbers:
___________________
D. SUPPORT SYSTEM: Family Community Specify: ________ Institutional Specify:
____________________________
E. COPING MECHANISM (Psychological Adaptation to Wellness)
Strengths:_________________________________ Weaknesses: _________________________________________________
F. HEALTH TEACHING on specific lifestyle and environment modifications
Restful Periods Smoke Avoidance Alcohol Moderation Stress Reduction Special Instructions:
__________________________________
G. ACTIVITY LEVEL: Independent Dependent Activities Allowed: ___________________ Activities Restricted:
_______________________
H. REACTION AND PRECAUTIONS TO DRUGS. (Refer to next Item)
Specific Instructions: ________________________________________________________________________________________________________________________________
I. GIVE HOME MEDICATIONS AS ORDERED (use separate sheet for this item only)
Medication Dose Frequency Precaution to Observe and Report
________________ _______ ______________ ______________________________________________________
________________ _______ ______________ ______________________________________________________
________________ _______ ______________ __________________________________
J. EXPECTED DATE OF FOLLOW UP CARE: Referral Given Not needed Specifics:
_____________________________________
K. ACTUAL DISCHARGE: Date and Time___________________ Mode: ___________________ Destination: ______ Condition on Discharge:
________________________
________________________________________ ________________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING
Kardex
DATE/ SHIFT:_________________________ AREA:________________________________
Date Date Date Date Date Special
Treatments Medications IV Fluids Laboratory
Procedures
Prepared by:__________________________ Noted by: ___________________________ Supervised
by:____________________________
TEAM LEADER CHARGE NURSE CLINICAL
INSTRUCTOR
