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Date: ___________Shift: ___________Nurse: ___________

NursingWorksheets.comMed-Surg / Telemetry

PATIENT 1

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	1100	1500
HR
BP
RR
Temp
SpO2
Pain

TELEMETRY

Rhythm:

Rate:

PR/QTc:

MOBILITY / FALL RISK

Fall Risk Score:

Mobility Level:

PT/OT Orders:

Assist Device:

DISCHARGE PLANNING

Est. DC Date:

Barriers:

Pending:

PATIENT EDUCATION

DIET / ACTIVITY

Diet:

Activity:

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	1100	1500
HR
BP
RR
Temp
SpO2
Pain

TELEMETRY

Rhythm:

Rate:

PR/QTc:

MOBILITY / FALL RISK

Fall Risk Score:

Mobility Level:

PT/OT Orders:

Assist Device:

DISCHARGE PLANNING

Est. DC Date:

Barriers:

Pending:

PATIENT EDUCATION

DIET / ACTIVITY

Diet:

Activity:

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.comMed-Surg / Telemetry

PATIENT 3

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	1100	1500
HR
BP
RR
Temp
SpO2
Pain

TELEMETRY

Rhythm:

Rate:

PR/QTc:

MOBILITY / FALL RISK

Fall Risk Score:

Mobility Level:

PT/OT Orders:

Assist Device:

DISCHARGE PLANNING

Est. DC Date:

Barriers:

Pending:

PATIENT EDUCATION

DIET / ACTIVITY

Diet:

Activity:

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	1100	1500
HR
BP
RR
Temp
SpO2
Pain

TELEMETRY

Rhythm:

Rate:

PR/QTc:

MOBILITY / FALL RISK

Fall Risk Score:

Mobility Level:

PT/OT Orders:

Assist Device:

DISCHARGE PLANNING

Est. DC Date:

Barriers:

Pending:

PATIENT EDUCATION

DIET / ACTIVITY

Diet:

Activity:

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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