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Nurse Report Sheet TemplatePatient InformationPatient’s Name : ____________________________Date of Birth: _________________________Gender: __________________Room No.: _________________________Medical InformationAttending Doctor: _____________________________________Allergies: _____________________________________Diagnosis: _____________________________________Medical History: _____________________________________Code Status: _____________________________________Blood Pressure: _____________________________________Heart Rate: _____________________________________Body Temperature: _____________________________________O2 Saturation : _____________________________________O2 : _____________________________________Repiratory Rate: _____________________________________Pain: _____________________________________Blood Sugar: _____________________________________Intake InformationBreakfast: ______________________________________Lunch: ______________________________________Dinner: ______________________________________Other : ______________________________________Output InformationFoley : ______________________________________BM: ______________________________________Emesis: ______________________________________Drains : ______________________________________Tubes: ______________________________________Ostomy Bag: ______________________________________Lab InformationLab Results: ______________________________________Required Lab Results: ______________________________________Future Procedures: ______________________________________ ................
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