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Patient Medical Chart Template

This document contains lab values and clinical information for a patient including hemoglobin, white blood cell count, platelet count, electrolytes, kidney and liver function tests. It notes input/output, drain status, and tasks completed. Vital assessments, ventilator settings, lines and tubes, wound care needs and plans of care are documented.

Uploaded by

Nurse Betty
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
2K views3 pages

Patient Medical Chart Template

This document contains lab values and clinical information for a patient including hemoglobin, white blood cell count, platelet count, electrolytes, kidney and liver function tests. It notes input/output, drain status, and tasks completed. Vital assessments, ventilator settings, lines and tubes, wound care needs and plans of care are documented.

Uploaded by

Nurse Betty
Copyright
© Attribution Non-Commercial (BY-NC)
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
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Patient Sticker Primary: COR status: Allergies: 20

Hgb WBC Plt Hct

Na K

Cl BUN Gluc HCO3 Cr

Patient Sticker

Hbg WBC Plt Hct

Na K

Cl HCO3

BUN Gluc Cr

24
I/O; empty drains/foley, linen, trash Ck labs

01

07 Primary: COR status: 01

02

Allergies: 20

21 New MAR 03 21 22 04 22 23 AM labs 05 23 24 06

02

New MAR 03

04

AM labs 05

Patient Sticker

Hgb WBC Plt Hct

Na K

Cl BUN Gluc HCO3 Cr

Patient Sticker
I/O; empty drains/foley, linen, trash Ck labs

Hbg WBC Plt Hct

Na K

Cl HCO3

BUN Gluc Cr

07
D-Dimer: Fib: Ca: Mg: Phos: Amylase/Lipase: ________/________ Bili T/D/I: ______/______/________ AST/ALT: ______/______ AlkPhos: Albumin: Allergies:

06
Primary Team: PMHx/CC: Neut: % COR status: Allergies:

Primary Team: PMHx/CC: Plans: Neuro: Social: Sedation: Restraints: Gtts: SvO2: Drains: CT: Output: Output:

COR status:

CV:

Lactate: Plans: Social: Sedation: Restraints: Gtts: SvO2: Drains: CT: Output: Output:

ECG: Ectopy: Pulm:

Air leak: Y/N

Neuro:

CT: GI:

Output:

Air leak: Y/N

ETT size:

Vent Mode: TV: RR: PEEP: FiO2: Secretions: Taped: cm @ teeth/lips

CV:

Lactate:

Glucose:

R/L NGT/DHT Taped @ _____cm TF Formula: ____________ @ _______ ml/hr Residual: _______ ml TPN @ _____ ml/hr Lipids @ ______ml/hr Rectal tube Y/N Output: _____ ml last 12 hrs

ECG: Ectopy: Pulm:

Air leak: Y/N

CT: Renal/GU: Foley Y/N MIVF: Decub: Dressing/Tx: CVL: R/L R/L PIV: R/L R/L I/O: _____ml/______ml @ _______ ml/hr GI:

Output:

Air leak: Y/N

ETT size:

Vent Mode: TV: RR: PEEP: FiO2: Secretions: Taped: cm @ teeth/lips

Skin:

Glucose:

R/L NGT/DHT Taped @ _____cm TF Formula: ____________ @ _______ ml/hr Residual: _____ ml TPN @ _____ ml/hr Lipids @ ______ml/hr Rectal tube Y/N Output: _____ ml last 12 hrs

Access:

Renal/GU:

Foley Y/N MIVF: Decub: Dressing/Tx: CVL: R/L

I/O: _____ml/______ml @ _______ ml/hr

Drsg change: Skin: ID: Labs: Tmax: _____F Cx: PT/PTT/INR: ____/_____/_____ Access:

PIV: R/L

Patient Sticker
R/L Drsg change: ID: Labs: Tmax: _____F Cx:

Hgb WBC Plt Hct R/L

Na K

Cl BUN Gluc HCO3 Cr

Patient Sticker

Hbg WBC Plt Hct

Na K

Cl HCO3

BUN Gluc Cr

Neut:

PT/PTT/INR: ____/_____/_____ D-Dimer: Fib: Ca: Mg: Phos: Amylase/Lipase: ________/________ Bili T/D/I: ______/______/________ AST/ALT: ______/______ AlkPhos: Albumin:

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