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Date: ___________Shift: ___________Nurse: ___________

NursingWorksheets.comEmergency Department

PATIENT 1

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	0900	1100	1300	1500	1700
HR
BP
RR
Temp
SpO2
Pain

TRIAGE

ESI Level:

Chief Complaint:

Arrival Time:

Mode:

DISPOSITION

Dispo:

Bed Requested:

Consults:

Transport ETA:

TIME-SENSITIVE PROTOCOLS

Stroke Alert

Time: ____

STEMI

Time: ____

Sepsis

Time: ____

PROCEDURES DONE

REASSESSMENT

Time	Findings	Initials

MEDICATIONS

Drug / Dose / Route	Time	Given	Notes

LABS

Na:

BUN:

Cr:

Glu:

WBC:

Hgb:

Plt:

Other:

IV ACCESS

Site/Gauge:

Fluid/Rate:

Date:

I&O

INTAKE

PO:

IV:

Blood:

Other:

Total:

OUTPUT

Urine:

Drain:

Emesis:

Other:

Total:

ASSESSMENT

PLAN / TASKS

NOTES

PATIENT 2

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	0900	1100	1300	1500	1700
HR
BP
RR
Temp
SpO2
Pain

TRIAGE

ESI Level:

Chief Complaint:

Arrival Time:

Mode:

DISPOSITION

Dispo:

Bed Requested:

Consults:

Transport ETA:

TIME-SENSITIVE PROTOCOLS

Stroke Alert

Time: ____

STEMI

Time: ____

Sepsis

Time: ____

PROCEDURES DONE

REASSESSMENT

Time	Findings	Initials

MEDICATIONS

Drug / Dose / Route	Time	Given	Notes

LABS

Na:

BUN:

Cr:

Glu:

WBC:

Hgb:

Plt:

Other:

IV ACCESS

Site/Gauge:

Fluid/Rate:

Date:

I&O

INTAKE

PO:

IV:

Blood:

Other:

Total:

OUTPUT

Urine:

Drain:

Emesis:

Other:

Total:

ASSESSMENT

PLAN / TASKS

NOTES

Date: ___________Shift: ___________Nurse: ___________

NursingWorksheets.comEmergency Department

PATIENT 3

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	0900	1100	1300	1500	1700
HR
BP
RR
Temp
SpO2
Pain

TRIAGE

ESI Level:

Chief Complaint:

Arrival Time:

Mode:

DISPOSITION

Dispo:

Bed Requested:

Consults:

Transport ETA:

TIME-SENSITIVE PROTOCOLS

Stroke Alert

Time: ____

STEMI

Time: ____

Sepsis

Time: ____

PROCEDURES DONE

REASSESSMENT

Time	Findings	Initials

MEDICATIONS

Drug / Dose / Route	Time	Given	Notes

LABS

Na:

BUN:

Cr:

Glu:

WBC:

Hgb:

Plt:

Other:

IV ACCESS

Site/Gauge:

Fluid/Rate:

Date:

I&O

INTAKE

PO:

IV:

Blood:

Other:

Total:

OUTPUT

Urine:

Drain:

Emesis:

Other:

Total:

ASSESSMENT

PLAN / TASKS

NOTES

PATIENT 4

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	0900	1100	1300	1500	1700
HR
BP
RR
Temp
SpO2
Pain

TRIAGE

ESI Level:

Chief Complaint:

Arrival Time:

Mode:

DISPOSITION

Dispo:

Bed Requested:

Consults:

Transport ETA:

TIME-SENSITIVE PROTOCOLS

Stroke Alert

Time: ____

STEMI

Time: ____

Sepsis

Time: ____

PROCEDURES DONE

REASSESSMENT

Time	Findings	Initials

MEDICATIONS

Drug / Dose / Route	Time	Given	Notes

LABS

Na:

BUN:

Cr:

Glu:

WBC:

Hgb:

Plt:

Other:

IV ACCESS

Site/Gauge:

Fluid/Rate:

Date:

I&O

INTAKE

PO:

IV:

Blood:

Other:

Total:

OUTPUT

Urine:

Drain:

Emesis:

Other:

Total:

ASSESSMENT

PLAN / TASKS

NOTES

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