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Nurse Shift Report SheetRoom: __________________Date: ________________General InformationName: _________________________Gender: ________Age: _______Date of Admission: _______________Diagnosis: ______________________Procedure: _____________________________Code Status: _____________________Allergies: _______________________________Hospital History Body SystemsNeuro: Orientation: _______________________Psych/Soc : _______________________Extermity Strength: _________________Activty : ___________________________Fall Precaution: _____________________Pupils: ____________________________Temperature: ______________________Weight: ___________________________Restraints: _________________________Neuro: Plan:Variance:Cardiovascular: Rhythm: __________________________Blood Pressure: ____________________“A” Line: __________________________Swan Ganz: ________________________Edema: ____________________________Pulses: ____________________________Drips: _____________________________Hep Lock: __________________________Cardiovascular: Plan:Variance: Respiratory:PUL: Coughing: _________________________Chest Tubes: _______________________ABG: ______________________________ExtubRR:Sputum: ____________________________Bipap: ______________________________Mode: _____________________________FiO2: _______________________________O2:Mask: ______________________________Triflow: ____________________________Cuff Pressure: _______________________Respiratory:Plan: Variance: GU: Foley: ______________________________Urine Output: _______________________Cath Care: PD: ________________________________Hemo: _____________________________SG: GU: Plan: Variance: Skin/Dressing/Incisions: Braden Scale: Specimens: Test, Labs: Procedures, hx, preps:Other: Other: Discharge Details: Variance to Discharge Plan: BarrierResolution: Consults: Teaching/Learning: Consults: Special Needs: ................
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