Epic SmartPhrases for Nurses — Free Searchable Library by Specialty

Rapid ED triage assessment

CC: [CHIEF COMPLAINT]
HPI: [HISTORY OF PRESENT ILLNESS]
Pertinent ROS: [REVIEW OF SYSTEMS]
Allergies: [NKDA / LIST]
Meds: [CURRENT MEDICATIONS]
VS: BP [__/__], HR [__], RR [__], Temp [__], O2 [__]%
PA: General appearance [ALERT/ORIENTED X3, DISTRESSED/COMFORTABLE].
Lungs: [CLEAR/CRACKLES/WHEEZES]
Heart: [RRR/IRREGULAR]
Abd: [SOFT/FIRM], [NON-TENDER/TENDER], [NO/+ REBOUND/GUARDING]
Extremities: [NO EDEMA/EDEMA], pulses intact.
Neuro: [GROSSLY INTACT/DEFICITS].
Assessment: [CHIEF COMPLAINT, STATUS/RESPONSE]
Plan: [DIAGNOSTICS, TREATMENTS, MONITORING, DISPOSITION]

ED pain assessment and management

Pain Level: [0-10]
Location: [SPECIFIC LOCATION]
Onset: [ACUTE/GRADUAL], [TIME]
Character: [SHARP/DULL/THROBBING/PRESSURE/OTHER]
Aggravating Factors: [LIST]
Relieving Factors: [LIST]
Associated Symptoms: [NAUSEA/VOMITING/DIZZINESS/OTHER]
Current Pain Interventions: [NONE/MEDICATIONS/POSITIONING/OTHER]
Allergies to Pain Meds: [NKDA/LIST]
Pain Management Plan: [MEDICATION/NON-PHARM/BOTH]
Provider Notified: [YES/NO], Time: [__]

ED triage note

Triage Acuity Level: [ESI LEVEL: 1/2/3/4/5]
Chief Complaint: [CC]
Level of Consciousness: [ALERT/VERBAL/PAIN/UNRESPONSIVE]
Vital Signs: BP [__/__], HR [__], RR [__], Temp [__], O2 [__]%
Pain Level: [0-10]
Mentor Impression: [STABLE/UNSTABLE/RED FLAG SYMPTOMS]
Safety: [NO SAFETY ISSUES/FALL RISK/ISOLATION/PRECAUTIONS NEEDED]
Room Assignment: [ROOM #/WAITING AREA]

ED abdominal assessment

Abd Appearance: [FLAT/DISTENDED/OBESE/SURGICAL SCAR]
Auscultation: [NORMAL BOWEL SOUNDS/ABSENT/HYPERACTIVE]
Bowel Sounds: All 4 quadrants [PRESENT/ABSENT]
Percussion: [TYMPANIC/DULL]
Palpation: [SOFT/FIRM], [TENDER/NON-TENDER]
Tenderness Location: [NONE/RUQ/LUQ/EPIGASTRIC/PERIUMBILICAL/RLQ/LLQ/SUPRAPUBIC]
Rebound Tenderness: [ABSENT/PRESENT AT ___]
Guarding: [NONE/VOLUNTARY/INVOLUNTARY]
Hernia: [ABSENT/PRESENT AT ___]
Mass: [NOT PALPATED/PALPATED AT ___]
Organomegaly: [NONE/LIVER/SPLEEN]
CVA Tenderness: [ABSENT/PRESENT]

CT/imaging order documentation

Imaging Ordered: [SPECIFIC STUDY]
Reason: [CLINICAL INDICATION]
Contrast: [NO CONTRAST/IV CONTRAST/ORAL CONTRAST]
Allergy to Contrast: [NONE/IODINE/SHELLFISH/OTHER]
Renal Function: [OBTAINED/PENDING/BASELINE GFR __]
Pregnancy Status: [DENIES/POSITIVE/UNKNOWN/CONFIRMED]
Time Ordered: [__]
Time to Imaging: [__]
Transport: [SELF/WHEELCHAIR/STRETCHER/REQUIRES MONITORING]
Escort: [NURSING/TECH/FAMILY MEMBER]
Result Available: [PENDING/COMPLETED]
Provider Notified of Results: [YES/NO], Time: [__]

Stroke alert / code stroke documentation

Last Known Well: [DATE/TIME]
Stroke Alert Activated: [TIME], By: [NAME/ROLE]
NIHSS Total: [SCORE], Performed by: [NAME], Time: [__]
Symptoms: [FACIAL DROOP / ARM DRIFT / SPEECH / VISUAL / GAIT]
Blood Glucose: [__] mg/dL, Time: [__]
BP on Arrival: [__/__], Repeat: [__/__]
CT Head Ordered: [TIME], Completed: [TIME], Result: [__]
Anticoagulants/Antiplatelets: [NONE / AGENT, LAST DOSE]
Thrombolytic Candidate: [YES/NO], Rationale: [__]
tPA/TNK Given: [YES/NO], Time: [__], Dose: [__]
Neuro Checks Q[__] min initiated at [TIME]
Disposition: [ICU / STROKE UNIT / TRANSFER TO __]

Sepsis screen and bundle documentation

Sepsis Screen: [POSITIVE/NEGATIVE], Time: [__]
Suspected Source: [PULMONARY / URINARY / ABDOMINAL / SKIN / UNKNOWN]
SIRS/qSOFA Criteria Met: [TEMP / HR / RR / WBC / ALTERED MENTATION / SBP <100]
Lactate Drawn: [TIME], Result: [__] mmol/L
Blood Cultures x2 Drawn Before Antibiotics: [YES/NO], Time: [__]
Antibiotic: [AGENT], Dose: [__], Started: [TIME]
Fluid Bolus: [__] mL [NS/LR] over [__], Started: [TIME]
Response to Fluid: BP [__/__], HR [__], MAP [__]
Repeat Lactate: [TIME], Result: [__]
Vasopressors: [NONE / AGENT, RATE]
Provider Notified: [NAME], Time: [__]
Disposition: [ICU / STEPDOWN / FLOOR]

Chest pain workup and serial monitoring

Onset: [TIME], Duration: [__], Character: [PRESSURE/SHARP/BURNING/TEARING]
Radiation: [NONE / JAW / ARM / BACK], Severity: [0-10]
Associated: [DIAPHORESIS / NAUSEA / DYSPNEA / SYNCOPE / NONE]
Cardiac History: [__], Risk Factors: [__]
12-Lead EKG Obtained: [TIME], Read by: [PROVIDER], Findings: [__]
Troponin #1: [TIME], Result: [__]; #2: [TIME], Result: [__]
ASA Given: [DOSE/TIME/NOT INDICATED], Nitro: [DOSE/TIME/HELD - REASON]
Pain After Intervention: [0-10]
Continuous Telemetry: [RHYTHM]
Provider Notified of Results: [TIME]
Disposition: [CATH LAB / OBSERVATION / ADMIT / DISCHARGE]

Violent/self-destructive restraint initiation and monitoring

Behavior Requiring Restraint: [SPECIFIC OBSERVED BEHAVIOR]
Less Restrictive Measures Attempted: [VERBAL DE-ESCALATION / REDIRECTION / MEDICATION / 1:1]
Restraint Type: [SOFT LIMB / LOCKED / 4-POINT], Applied: [TIME]
Order Obtained From: [PROVIDER], Time: [__]
Face-to-Face Evaluation Completed: [TIME], By: [__]
Q15 Monitoring: circulation [INTACT], skin [INTACT], ROM performed, hydration/toileting offered
Behavior at Reassessment: [__]
Release Criteria Discussed With Patient: [YES/NO]
Restraint Discontinued: [TIME], Behavior at Release: [__]
Family/Guardian Notified: [YES/NO/NA], Time: [__]
Debrief Completed: [YES/NO]

ED behavioral health hold and safety documentation

Presenting Concern: [SI / HI / GRAVE DISABILITY / INTOXICATION / OTHER]
Legal Status: [VOLUNTARY / INVOLUNTARY HOLD], Initiated by: [__], Time: [__]
Safety Search Completed: [TIME], By: [__], Items Removed: [LIST / NONE]
Patient Changed Into Hospital Garments: [YES/NO]
Observation Level: [1:1 / LINE OF SIGHT / Q15], Started: [TIME]
Environment Secured: [LIGATURE RISKS REMOVED / SAFE ROOM]
Behavior/Affect: [DESCRIPTION]
PRN Medication: [AGENT/DOSE/ROUTE/TIME/RESPONSE / NONE]
Social Work / Crisis Consulted: [NAME], Time: [__]
Disposition Plan: [INPATIENT PSYCH / CRISIS STABILIZATION / DISCHARGE WITH PLAN]

Pediatric fever assessment in the ED

Age: [__], Weight: [__] kg
Tmax at Home: [__], Route: [__], Last Antipyretic: [AGENT/DOSE/TIME]
Temp on Arrival: [__] [ORAL/TEMPORAL/RECTAL/AXILLARY]
VS: HR [__], RR [__], BP [__/__], SpO2 [__]%
Appearance: [PLAYFUL / CONSOLABLE / IRRITABLE / LETHARGIC / TOXIC]
Hydration: mucous membranes [MOIST/DRY], last void [__], cap refill [__] sec
Immunizations: [UP TO DATE / DELAYED / UNKNOWN]
Associated Symptoms: [COUGH / RASH / VOMITING / DIARRHEA / EAR PULLING / NONE]
Interventions: [ANTIPYRETIC AGENT/DOSE/TIME], [PO/IV FLUIDS]
Temp Recheck: [__] at [TIME], Appearance After: [__]
Caregiver Education: return precautions reviewed, teach-back [COMPLETED]

Trauma activation primary and secondary survey

Trauma Activation Level: [1/2/3], Time: [__], Mechanism: [__]
Arrival: [EMS / PRIVATE VEHICLE / TRANSFER], Time: [__]
Primary Survey — A: [PATENT / ADJUNCT], B: [BREATH SOUNDS, RR, SpO2], C: [HR, BP, PULSES, BLEEDING CONTROL], D: [GCS __ (E__V__M__), PUPILS], E: [FULLY EXPOSED, WARMED]
C-Spine Precautions: [MAINTAINED / CLEARED BY __]
Access: [__ gauge x __ sites], Labs/T&S Sent: [TIME]
FAST/Imaging: [STUDY, TIME, RESULT]
Secondary Survey Findings: [HEAD/NECK/CHEST/ABD/PELVIS/EXTREMITIES/BACK]
Interventions: [BLOOD PRODUCTS / TXA / CHEST TUBE / SPLINTING / OTHER]
Tetanus Status: [UTD / GIVEN TIME __]
Disposition: [OR / ICU / CT / TRANSFER], Time: [__]

ED discharge instructions and teach-back

Discharge Diagnosis: [__]
VS at Discharge: BP [__/__], HR [__], RR [__], Temp [__], SpO2 [__]%, Pain [0-10]
Discharge Instructions Reviewed: [DIAGNOSIS / MEDICATIONS / ACTIVITY / DIET / WOUND CARE]
New Prescriptions: [LIST], Pharmacy: [__]
Follow-Up: [PROVIDER/CLINIC], Within: [__ DAYS], Appointment [SCHEDULED/PATIENT TO CALL]
Return Precautions Given For: [SPECIFIC SYMPTOMS]
Teach-Back: patient/caregiver [ABLE/UNABLE] to restate instructions
Interpreter Used: [NO / YES — LANGUAGE, ID #]
Barriers Identified: [TRANSPORTATION / COST / HOUSING / NONE], Referral: [__]
Ambulation/Transport at Discharge: [AMBULATORY / WHEELCHAIR / WITH __]

ICU bedside handoff/SBAR template

SITUATION:
Patient: [NAME, AGE, DIAGNOSIS]
Code Status: [FULL CODE/DNR/DNI/OTHER]
Current Status: [STABLE/UNSTABLE/DECLINING]

BACKGROUND:
Admission Reason: [PRIMARY DIAGNOSIS]
Relevant History: [PMHx, SURGICAL Hx, ALLERGIES]
Current Medications: [CRITICAL MEDS]
Recent Events: [PROCEDURES, CHANGES IN STATUS]

ASSESSMENT:
Clinical Impression: [CURRENT STATUS]
Key Concerns: [LIST]
Monitoring Parameters: [HR, BP, RR, O2, TEMP, NEURO, RENAL OUTPUT]

RECOMMENDATION:
Plan for Next 4-8 Hours: [MONITORING, INTERVENTIONS, ANTICIPATED CHANGES]
Provider Notification: [ITEMS REQUIRING MD CONTACT]
Families Needs: [UPDATES PROVIDED/PENDING]

Comprehensive ICU shift assessment

Level of Consciousness: [ALERT/ORIENTED X__/SEDATED/UNRESPONSIVE]
Pain Level: [0-10 or SEDATION SCALE SCORE]
Respiratory: On [VENTILATOR SETTINGS/ROOM AIR/O2 via ___]
O2 Sat: [__]% on current support
Spontaneous RR: [__], Assist Control: [__]
Lungs: [CLEAR/CRACKLES/WHEEZES/DIMINISHED]
Secretions: [SCANT/MODERATE/COPIOUS], [CLEAR/YELLOW/GREEN]
Cardiac: HR [__], Rhythm [RRR/AFIB/OTHER], BP [__/__]
Urine Output Last 4 hrs: [__] mL
Stool: [NONE/FORMED/LOOSE/DIARRHEA]
Skin: [INTACT/REDNESS AT ___/WOUND STAGE ___]
Lines/Tubes: [ETT/NG/FOLEY/CENTRAL LINE/PICC] all intact and secured
IVs: [PATENT/INFILTRATED at ___]
Neuro: [GROSSLY INTACT/DEFICITS WITH ___]
Nutrition: [NPO/TF @ ___ cal/hr/TPN/PO]
Psychosocial: [COPING/ANXIOUS/AGITATED/WITHDRAWN]

ICU neurological assessment

Level of Consciousness: [ALERT/ORIENT X__/SEDATED/UNRESPONSIVE]
GCS: E[__] V[__] M[__] = [__]/15
Pupils: [EQUAL/UNEQUAL], [ROUND/SLUGGISH/BRISK], size [__] mm
EyeContact: [YES/NO]
Speech: [CLEAR/SLURRED/APHASIA/INTUBATED]
Follows Commands: [YES/NO]
Movement: [INTACT ALL EXTREMITIES/DEFICITS WITH ___]
Strength: [5/5 ALL/DEFICIT ___]
Sensation: [INTACT/DIMINISHED at ___]
Reflexes: [NORMAL/HYPERREFLEXIC/HYPOREFLEXIC]
Cranial Nerves II-XII: [INTACT/DEFICIT WITH CN ___]
Speech: [NORMAL/SLURRED/INCOHERENT/NONE]
Orientation: [PERSON/PLACE/TIME] [INTACT/DEFICITS]
Memory: [INTACT/IMPAIRED]
Mood/Affect: [APPROPRIATE/INAPPROPRIATE/FLAT]
Agitation: [NONE/MILD/MODERATE/SEVERE]

ICU drains, lines, tubes assessment

ETT: [SIZE __ mm], Depth [__ cm], [SECURE/LOOSE], Secretions [SCANT/MOD/COPIOUS]
NG Tube: [IN PLACE/NOT IN PLACE], [PATENT/CLOGGED], Placement verified [YES/NO]
Foley Catheter: [IN PLACE/NOT IN PLACE], Urine [CLEAR/YELLOW/AMBER/BURGUNDY], Output [__] mL last 4 hrs
Central Line: [LOCATION: ___], [INTACT/OCCLUSIVE DRESSING INTACT], [PATENT/SLUGGISH]
PICC Line: [LOCATION: ___], [PATENT/SLUGGISH], [DRESSING INTACT/CHANGED]
Chest Tube: [LOCATION: ___], Drainage [SCANT/MOD/COPIOUS], [SEROSANG/BLOOD TINGED/CLEAR]
Biliary Drain: [DRAINAGE: __/24 hr]
Jackson-Pratt: [LOCATION: ___], [DRAINAGE COLOR/AMOUNT]
Surgical Drains: [LOCATION: ___], [DRAINAGE CHARACTERISTICS]
All lines secured, no signs of infection or compromise.

Sedation assessment and titration

Sedation Goal: [ALERT/CALM/LIGHT SEDATION/MODERATE/DEEP]
Current Sedative: [PROPOFOL/MIDAZOLAM/LORAZEPAM/DEXMEDETOMIDINE/OTHER]
Infusion Rate: [__ mcg/kg/min or __ mL/hr]
Sedation Assessment Tool: [RASS SCORE: __] OR [MAAS SCORE: __]
Response to Commands: [FOLLOWS/DOES NOT FOLLOW]
Client Comfort: [COMFORTABLE/RESTLESS/AGITATED]
Physical Agitation: [NONE/MILD/MODERATE/SEVERE]
Response to Stimulation: [BRISK/DELAYED/MINIMAL/NONE]
Spont Ventilation: [ADEQUATE/INADEQUATE/ASSIST NEEDED]
Analgesia: [ADEQUATE/BREAKTHROUGH PAIN]
Adjustments Made: [NONE/INCREASE by __/DECREASE by __]
Time of Adjustment: [__]
Response to Adjustment: [IMPROVED/UNCHANGED/WORSENED]

Sepsis screening and management

Sepsis Criteria Met: [YES/NO]
Suspected Source of Infection: [RESPIRATORY/URINARY/ABDOMINAL/SKIN/CENTRAL LINE/UNKNOWN]
Fever/Hypothermia: [TEMP __ °C/°F]
Tachycardia: [HR __ bpm]
Tachypnea: [RR __ /min]
Alteration in Mental Status: [YES/NO]
Hypotension: [SBP __ mmHg]
Lactate Level: [__ mmol/L]
Cultures Obtained: [YES/NO], [BLOOD x2/URINE/SPUTUM/OTHER]
Time of Culture: [__]
Antibiotics Initiated: [TIME __], [ANTIBIOTIC REGIMEN: ___]
Fluid Bolus Given: [YES/NO], [AMOUNT: __ mL]
Vasopressor Requirement: [NO/YES - AGENT: ___]
Source Control: [OBTAINED/PENDING]
Reassessment: [PATIENT RESPONDING/NO IMPROVEMENT/WORSENED]

Ventilator settings, tolerance, and weaning readiness

Airway: [ETT SIZE __ / TRACH SIZE __], Secured at [__] cm at lip/gum
Cuff Pressure: [__] cm H2O, Checked: [TIME]
Mode: [AC-VC / AC-PC / PRVC / PSV / SIMV]
Settings: Vt [__] mL, RR [__], PEEP [__], FiO2 [__]%, PS [__]
Measured: Vt [__], Total RR [__], Ppeak [__], Pplat [__]
ABG: pH [__], PaCO2 [__], PaO2 [__], HCO3 [__], SpO2 [__]%
Breath Sounds: [__], Secretions: [AMOUNT/COLOR/CONSISTENCY]
Sedation: [AGENT/RATE], RASS Goal [__], Actual [__]
VAP Bundle: HOB >30 [YES/NO], oral care [TIME], SAT/SBT [DONE/HELD - REASON]
Weaning Readiness: [RSBI __ / NOT A CANDIDATE - REASON]
RT and Provider Notified of: [__]

Vasoactive drip titration and hemodynamic response

Agent: [NOREPI / EPI / VASO / PHENYL / DOBUTAMINE / MILRINONE]
Concentration: [__], Line: [CENTRAL — SITE / PERIPHERAL — SITE], Patency Verified
Starting Rate: [__] mcg/kg/min at [TIME]
Titration Parameter: MAP goal [__] mmHg per [PROVIDER ORDER]
Current Rate: [__], Last Titration: [TIME], Direction: [UP/DOWN]
Hemodynamics: BP [__/__], MAP [__], HR [__], Rhythm [__], CVP [__]
Perfusion: cap refill [__] sec, extremities [WARM/COOL], UOP [__] mL/hr, lactate [__]
Site Assessment: [NO INFILTRATION / EXTRAVASATION — ACTION TAKEN]
Additional Support: [FLUIDS / STEROIDS / MECHANICAL]
Provider Notified: [NAME/TIME/REASON]

Continuous renal replacement therapy shift documentation

Modality: [CVVH / CVVHD / CVVHDF / SCUF], Started: [DATE/TIME]
Access: [CATH TYPE/SITE], Patency: [GOOD / POSITIONAL], Dressing: [CDI]
Blood Flow Rate: [__] mL/min, Effluent Dose: [__] mL/kg/hr
Replacement/Dialysate: [FLUID], Rate: [__] mL/hr
Net UF Goal: [__] mL/hr, Actual Net Removed This Shift: [__] mL
Anticoagulation: [NONE / HEPARIN / CITRATE], Monitoring: [PTT / iCa SYSTEMIC __ / POST-FILTER __]
Circuit Pressures: access [__], filter [__], effluent [__], TMP [__]
Filter Changes/Clotting Events: [NONE / TIME AND REASON]
Electrolytes: K [__], Phos [__], Mg [__], Ca [__], Bicarb [__]
Hemodynamic Tolerance: MAP [__], pressor changes [__]
Nephrology Notified of: [__], Time: [__]

Sedation, agitation, and delirium screening

RASS Goal: [__], RASS Actual This Shift: [__] at [TIMES]
CAM-ICU: [POSITIVE / NEGATIVE / UNABLE — RASS -4/-5], Time: [__]
Feature 1 Acute Change/Fluctuation: [YES/NO]
Feature 2 Inattention: [YES/NO], Errors: [__]
Feature 3 Altered LOC: [YES/NO]
Feature 4 Disorganized Thinking: [YES/NO], Errors: [__]
CPOT/Pain Score: [__], Intervention: [__]
Sedation: [AGENT/RATE], Daily Awakening Trial: [PERFORMED / HELD — REASON]
Non-Pharm Measures: [SLEEP HYGIENE / EARLY MOBILITY / GLASSES-HEARING AIDS / FAMILY PRESENCE / REORIENTATION]
Mobility Level: [BED REST / DANGLE / STAND / CHAIR / AMBULATE __ FT]
Provider Notified of Positive Screen: [YES/NO], Time: [__]

Daily lines, tubes, and drains audit

Central Line: [TYPE/SITE], Day [__], Dressing [CDI/CHANGED TIME __], CHG Disc [INTACT], Necessity Reviewed: [CONTINUE/REMOVE]
Arterial Line: [SITE], Day [__], Waveform [DAMPENED/NORMAL], Zeroed [TIME], Allen Test/Perfusion Distal [INTACT]
Urinary Catheter: [TYPE], Day [__], Indication [__], Necessity Reviewed: [CONTINUE/REMOVE], Securement [INTACT]
ETT/Trach: Day [__], Secured, Skin Under Device [INTACT]
Enteral Tube: [TYPE/SIZE], Placement Verified [METHOD], Residual [__] mL
Drains: [TYPE/SITE], Output [__] mL, Character [__]
Peripheral IVs: [SITE/GAUGE/DAY], Patent, Site [WNL]
CLABSI/CAUTI Prevention Bundle: [COMPLETE / GAPS: __]
Removal Recommended To Provider: [DEVICE], Time: [__]

Prone positioning procedure and tolerance

Indication: [ARDS, P/F RATIO __]
Consent/Provider Order: [PROVIDER], Time: [__]
Pre-Prone: BP [__/__], HR [__], SpO2 [__]%, FiO2 [__], PEEP [__], ABG [__]
Team Present: [ROLES/COUNT], Airway Secured By: [__]
Prone Initiated: [TIME], Planned Duration: [__] hrs
Post-Prone Vitals at 15 min: BP [__/__], HR [__], SpO2 [__]%
P/F Ratio After Proning: [__]
Pressure Injury Prevention: face/chest/pelvis/knees offloaded, repositioned q[__] hrs, eye care [DONE]
Lines/Tubes Verified Post-Turn: [ETT DEPTH / CENTRAL LINE / TUBES INTACT]
Complications: [NONE / DESLODGEMENT / DESATURATION / HEMODYNAMIC INSTABILITY]
Supinated: [TIME], Reason: [SCHEDULED / INTOLERANCE / IMPROVEMENT]

Family meeting and goals of care communication

Date/Time: [__], Location: [BEDSIDE / CONFERENCE ROOM / VIRTUAL]
Participants: [FAMILY NAMES/RELATIONSHIPS], [PROVIDERS/ROLES], Interpreter: [NO / YES — LANGUAGE]
Surrogate Decision Maker: [NAME/RELATIONSHIP], Documentation: [POA / NEXT OF KIN]
Clinical Update Provided By: [PROVIDER]
Family Understanding of Condition: [ACCURATE / PARTIAL / DESCRIBE]
Patient's Previously Expressed Wishes: [__]
Questions/Concerns Raised: [__]
Decisions Made: [FULL CODE / DNR / DNI / COMFORT MEASURES / TIME-LIMITED TRIAL / NO CHANGE]
Code Status After Meeting: [__], Order Updated: [YES/NO], Time: [__]
Support Services Offered: [CHAPLAIN / SOCIAL WORK / PALLIATIVE / ETHICS]
Next Meeting Planned: [DATE/TIME]

Med-Surg comprehensive assessment

Chief Complaint: [CC]
History: [HPI WITH TIMELINE]
Allergies: [NKDA/LIST]
Current Medications: [LIST]
Vital Signs: BP [__/__], HR [__], RR [__], Temp [__], Pain [0-10]
General: [ALERT/ORIENTED X3, COMFORTABLE/DISTRESSED]
Respiratory: [UNLABORED/LABORED], Lungs [CLEAR/DIMINISHED/CRACKLES]
Cardiac: HR [RRR/IRREGULAR], BP [SBP/DBP], Peripheral Pulses [INTACT]
Abdomen: [SOFT/FIRM], [NON-TENDER/TENDER], [NO/+ REBOUND], BS [NORMAL/ABSENT]
Extremities: [NO EDEMA/EDEMA], Skin [WARM/COOL], Color [PALE/FLUSHED/NORMAL]
Skin: [INTACT/BREAKDOWN AT ___], Turgor [GOOD/POOR]
Neuro: [GROSSLY INTACT/FOCAL DEFICITS]
Mood/Affect: [APPROPRIATE/ANXIOUS/DEPRESSED]
Psychosocial: [COPING WELL/NEEDS SUPPORT]

Post-operative assessment

Time from OR: [__ minutes/hours]
Anesthesia Type: [GENERAL/REGIONAL/LOCAL]
Surgical Procedure: [PROCEDURE NAME]
Incision: [LOCATION], [INTACT/APPROXIMATED], [CLEAN/SLIGHT DRAINAGE/SIGNIFICANT DRAINAGE]
Dressings: [INTACT/REINFORCED/CHANGED]
Drains: [LOCATION], [AMOUNT/COLOR/CONSISTENCY], [CLAMPED/PATENT]
Vital Signs: BP [__/__], HR [__], RR [__], Temp [__]
O2 Sat: [__]% on [ROOM AIR/O2 via ___]
Level of Consciousness: [ALERT/ORIENTED X__/DROWSY/UNRESPONSIVE]
Nausea/Vomiting: [NONE/MILD/MODERATE/SEVERE]
Pain Level: [0-10 at location ___]
Movement: [FULL/LIMITED/NONE]
Voided Post-Op: [NOT YET/__mL]
Gag Reflex: [PRESENT/ABSENT]
Diet: [NPO/CLEAR LIQUIDS/REGULAR]
Activity: [BED REST/ACTIVITY AS TOLERATED/AMBULATING]
Compression Devices: [ON/OFF], Extremities [NO EDEMA/EDEMA]
Provider Notification: [NOT NEEDED/YES - RE: ___]

Pain assessment and management

Pain Level: [0-10]
Location: [SPECIFIC ANATOMICAL LOCATION]
Onset: [ACUTE/CHRONIC], Duration: [__ minutes/hours]
Character: [SHARP/DULL/THROBBING/ACHING/BURNING]
Aggravating Factors: [MOVEMENT/POSITION/ACTIVITIES]
Relieving Factors: [REST/POSITION/MEDICATIONS/HOT/COLD]
Associated Symptoms: [NAUSEA/DIZZINESS/WEAKNESS/NONE]
Current Pain Medications: [LAST DOSE __, TIME __]
Response to Last Dose: [EFFECTIVE/PARTIALLY EFFECTIVE/INEFFECTIVE]
Adjunctive Measures Used: [HEAT/COLD/POSITIONING/DISTRACTION]
Barriers to Pain Management: [ALLERGIES/NAUSEA/ADDICTION CONCERNS/OTHER]
Plan: [CONTINUE CURRENT REGIMEN/ADJUST DOSE/CHANGE MEDICATION/ADD ADJUNCT]
Provider Contacted: [YES/NO]

Discharge instructions template

DISCHARGE INSTRUCTIONS
Date Discharged: [__]
Discharge Medications: [LIST WITH DOSE/FREQUENCY]
Diet: [REGULAR/RESTRICTED - SPECIFY: ___]
Activity: [AS TOLERATED/RESTRICTIONS: ___]
Wound Care: [KEEP CLEAN AND DRY/DRESSING CHANGE INSTRUCTIONS]
When to Change Dressing: [EVERY __ HOURS/IF SOILED]
RedFlag Symptoms: [FEVER >101.5, INCREASED PAIN, DRAINAGE/REDNESS, SWELLING, DIFFICULT BREATHING]
Follow-up Appointments: [PROVIDER: __, DATE/TIME: __]
Physical Therapy: [YES/NO], [FACILITY: ___]
Home Health: [YES/NO], [FREQUENCY: ___]
Medical Equipment: [NONE/WALKER/CRUTCHES/WHEELCHAIR/HEATING PAD]
Prescription Refills: [WRITTEN FOR: ___]
Patient Understanding: [VERBALIZES UNDERSTANDING/REQUIRES REINFORCEMENT]
Caregiver Present: [YES/NO]
Education Material Provided: [YES/NO]

Full med-surg shift assessment

Neuro: [ALERT AND ORIENTED X__], speech [CLEAR], follows commands, MAE
Cardiac: rate [__], rhythm [__], pulses [__], cap refill [__] sec, edema [NONE/__]
Respiratory: [UNLABORED], lungs [CLEAR/DIMINISHED/CRACKLES/WHEEZES], SpO2 [__]% on [RA/__]
GI: abdomen [SOFT/DISTENDED], bowel sounds [x4 QUADRANTS], last BM [DATE], diet [__], tolerating [YES/NO]
GU: voiding [SPONTANEOUSLY / CATHETER], urine [CLEAR YELLOW/__], output [__] mL
Skin: [WARM, DRY, INTACT / WOUNDS — SEE WOUND NOTE], Braden [__]
Mobility: [INDEPENDENT / ASSIST x__ / BED REST], Morse Fall Score [__], interventions [__]
Pain: [0-10], location [__], intervention [__], reassessed [SCORE/TIME]
IV: [SITE/GAUGE/DAY], patent, no [REDNESS/SWELLING], fluids [__]
Safety: bed low, call light in reach, [NON-SKID FOOTWEAR], [ALARM ON/OFF]
Plan This Shift: [__]

Wound assessment and dressing change

Wound Location: [SPECIFIC ANATOMIC SITE]
Etiology: [SURGICAL / PRESSURE / VENOUS / ARTERIAL / DIABETIC / TRAUMATIC]
Stage/Classification: [__], Date First Documented: [__]
Measurements: length [__] cm x width [__] cm x depth [__] cm
Undermining/Tunneling: [NONE / __ cm at __ o'clock]
Wound Bed: [__% GRANULATION / __% SLOUGH / __% ESCHAR / __% EPITHELIAL]
Exudate: [NONE/SCANT/MODERATE/LARGE], [SEROUS/SEROSANGUINOUS/PURULENT], odor [ABSENT/PRESENT]
Periwound: [INTACT / MACERATED / ERYTHEMA __ cm / INDURATION]
Pain During Dressing Change: [0-10], premedicated [YES/NO — AGENT/TIME]
Cleansed With: [__], Dressing Applied: [PRODUCT], Frequency: [__]
Wound Care/Provider Notified of: [__]
Progress Since Last Assessment: [IMPROVED / UNCHANGED / DETERIORATED]

Post-fall assessment and reporting

Time of Fall: [__], Discovered vs Witnessed: [__], Witness: [NAME/ROLE]
Location: [ROOM / BATHROOM / HALLWAY]
Patient Account: [PATIENT STATEMENT]
Activity at Time of Fall: [AMBULATING / TRANSFERRING / REACHING / UNKNOWN]
Contributing Factors: [MEDICATIONS / TOILETING / FOOTWEAR / LINES / ENVIRONMENT / ORTHOSTASIS]
Injury: [NONE APPARENT / SPECIFY LOCATION AND TYPE]
Head Strike: [YES/NO/UNKNOWN], Anticoagulated: [YES/NO — AGENT]
Immediate Assessment: LOC [__], VS [__], neuro checks initiated q[__], ROM all extremities, pain [0-10]
Provider Notified: [NAME], Time: [__], Orders Received: [IMAGING / NEURO CHECKS / NONE]
Family Notified: [NAME/RELATIONSHIP], Time: [__]
Fall Prevention Plan Updated: [BED ALARM / SITTER / TOILETING SCHEDULE / PT CONSULT]
Event Report Filed: [YES], Time: [__]

Isolation precautions and patient education

Precaution Type: [CONTACT / CONTACT PLUS / DROPLET / AIRBORNE / ENTERIC]
Indication: [ORGANISM / RULE-OUT / SYMPTOM-BASED]
Initiated: [DATE/TIME], By: [__], Order From: [PROVIDER]
Signage Posted: [YES], PPE Stocked Outside Room: [YES]
Room Type: [PRIVATE / NEGATIVE PRESSURE — VERIFIED TIME __]
Dedicated Equipment in Room: [BP CUFF / STETHOSCOPE / THERMOMETER]
Patient Education Provided: rationale, hand hygiene, visitor requirements, room-leaving restrictions
Teach-Back: [COMPLETED / BARRIERS]
Visitors Educated: [YES/NO/NA]
Transport Precautions Communicated To: [DEPARTMENT], Time: [__]
Discontinuation Criteria: [__], Reviewed With Infection Prevention: [YES/NO]

Blood product transfusion documentation

Product: [PRBC / FFP / PLATELETS / CRYO], Unit #: [__], Volume: [__] mL
Indication: [HGB __ / ACTIVE BLEEDING / PLATELET COUNT __]
Consent Verified: [YES], Type and Screen Current: [DATE]
Two-Person Verification Completed With: [NAME/ROLE], Time: [__]
Access: [SITE/GAUGE], Filter Tubing With [NS] Primed
Pre-Transfusion VS: T [__], BP [__/__], HR [__], RR [__], SpO2 [__]%
Start Time: [__], Initial Rate: [__] mL/hr
VS at 15 min: T [__], BP [__/__], HR [__], RR [__], SpO2 [__]%
VS Q[__] Thereafter: [__]
Completion Time: [__], Total Volume Infused: [__] mL
Reaction: [NONE / DESCRIBE — TRANSFUSION STOPPED, PROVIDER AND BLOOD BANK NOTIFIED, TIME __]
Post-Transfusion VS and Labs: [__]

Code status verification and advance directive review

Current Code Status: [FULL CODE / DNR / DNR-DNI / COMFORT MEASURES ONLY]
Order Verified in Chart: [YES], Date/Provider: [__]
Advance Directive on File: [YES/NO], Type: [LIVING WILL / POLST / MOLST / DPOA]
Healthcare Proxy: [NAME/RELATIONSHIP/PHONE]
Discussion Held With: [PATIENT / FAMILY / BOTH], Time: [__]
Patient Decision-Making Capacity: [INTACT / IMPAIRED — SURROGATE ACTING]
Patient's Stated Goals: [__]
Questions Raised: [__]
Provider Notified of Change: [NAME], Time: [__], Order Updated: [YES/NO]
Armband/EHR Flag Updated: [YES/NO]
Palliative or Ethics Consult: [PLACED / NOT INDICATED]

Rapid response team activation

Trigger: [VS CRITERIA / MENTAL STATUS CHANGE / STAFF CONCERN / FAMILY CONCERN]
Time Called: [__], Team Arrival: [__]
VS at Activation: BP [__/__], HR [__], RR [__], Temp [__], SpO2 [__]% on [__]
Mental Status: [BASELINE / CHANGED — DESCRIBE]
Events Preceding: [__]
Interventions Prior to Arrival: [O2 / POSITIONING / FLUIDS / EKG / GLUCOSE]
Interventions by RRT: [__]
Diagnostics Obtained: [EKG / ABG / LABS / IMAGING], Results: [__]
Provider at Bedside: [NAME], Time: [__]
Outcome: [REMAINED ON UNIT WITH NEW ORDERS / TRANSFERRED TO __ AT TIME __ / CODE CALLED]
Family Notified: [NAME], Time: [__]
Handoff Given To: [RECEIVING RN/UNIT], Time: [__]

Medication reconciliation on admission or transfer

Reconciliation Type: [ADMISSION / TRANSFER / DISCHARGE]
Sources Used: [PATIENT / FAMILY / PHARMACY / PRIOR RECORDS / MED LIST BROUGHT IN]
Historian Reliability: [RELIABLE / LIMITED — REASON]
Home Medications Reviewed: [COUNT], Including [PRESCRIPTION / OTC / HERBAL / INHALERS / INJECTABLES]
Last Dose Times Confirmed For: [ANTICOAGULANTS / INSULIN / ANTIHYPERTENSIVES / SEIZURE MEDS / OPIOIDS]
High-Risk Medications Identified: [__]
Allergies/Intolerances Updated: [AGENT — REACTION]
Discrepancies Found: [__]
Provider Notified of Discrepancies: [NAME], Time: [__], Resolution: [__]
Medications Held on Admission and Rationale: [__]
Patient/Family Education on Changes: [PROVIDED / TEACH-BACK COMPLETED]

Glucose monitoring and hypoglycemia management

Blood Glucose: [__] mg/dL, Time: [__], Source: [FINGERSTICK / VENOUS]
Symptoms: [ASYMPTOMATIC / DIAPHORESIS / TREMOR / CONFUSION / WEAKNESS / NONE]
Related Factors: [NPO / MISSED MEAL / INSULIN TIMING / STEROIDS / TUBE FEED HELD]
Insulin Given: [TYPE/UNITS/ROUTE/TIME] or [HELD — REASON]
Hypoglycemia Protocol Initiated: [YES/NO], Treatment: [__ g ORAL CARB / D50 __ mL IV / GLUCAGON]
Recheck Glucose: [__] mg/dL at [TIME]
Repeat Treatment Required: [YES/NO]
Meal/Snack Provided: [YES/NO], Time: [__]
Provider Notified: [NAME], Time: [__], New Orders: [__]
Carb Coverage/Sliding Scale Reviewed: [__]
Patient Education: symptom recognition, when to call, [TEACH-BACK COMPLETED]

Urinary catheter insertion and daily necessity review

Indication: [URINARY RETENTION / STRICT I&O IN CRITICAL ILLNESS / PERIOPERATIVE / OPEN SACRAL WOUND / COMFORT AT END OF LIFE]
Insertion Date/Time: [__], Catheter Day: [__]
Catheter Type/Size: [__], Balloon: [__] mL sterile water
Insertion: sterile technique maintained, [# ATTEMPTS], assistance from [__]
Urine on Insertion: [AMOUNT/COLOR/CLARITY/ODOR]
Securement Device: [IN PLACE], Tubing: [DEPENDENT LOOP FREE], Bag: [BELOW BLADDER, OFF FLOOR]
Peri Care: performed [FREQUENCY], meatal site [WNL / DRAINAGE / IRRITATION]
Output This Shift: [__] mL, Character: [__]
Symptoms of CAUTI: [NONE / FEVER / SUPRAPUBIC PAIN / CLOUDY-MALODOROUS URINE]
Daily Necessity Reviewed: [CONTINUE — INDICATION STILL MET / REMOVAL RECOMMENDED TO PROVIDER]
Removed: [DATE/TIME], First Void After Removal: [TIME/AMOUNT]

L&D maternal-fetal assessment

Admission Time: [__]
Gravida: [__], Para: [__], Term/Preterm/Abortion
EDD: [__], Weeks Gestation: [__+_]
Presenting Complaint: [LABOR PAINS/ROM/BLEEDING/OTHER]
Contraction Pattern: [FREQUENCY __ min, DURATION __ sec, INTENSITY MILD/MOD/STRONG]
Fetal Heart Rate: [__] bpm, Pattern [REACTIVE/NON-REACTIVE/VARIABLE DECELS]
Maternal Vital Signs: BP [__/__], HR [__], RR [__], Temp [__]
Vaginal Exam: [INTACT/BLOOD STAINED], Dilation [__ cm], Effacement [__%, THICK/THIN], Station [__]
Position: [VERTEX/BREECH/TRANSVERSE]
Membrane Status: [INTACT/RUPTURED], [TIME __], [CLEAR/MECONIUM STAINED]
Last Meal: [TIME __], Food: [___]
Pregnancy Complications: [NONE/GDM/PIH/PREECLAMPSIA/OTHER]
Labor Status: [LATENT/ACTIVE/TRANSITION]
Fetal Status: [REASSURING/CONCERNING]
Maternal Comfort: [COPING WELL/DISTRESSED]

Rupture of Membranes documentation

Time of ROM: [__]
Client Report: [GUSH/LEAK/UNCERTAIN]
Fern Test: [POSITIVE/NEGATIVE/NOT DONE]
Nitrazine Test: [POSITIVE (BLUE)/NEGATIVE (YELLOW)/NOT DONE]
Amniotic Fluid: [CLEAR/MECONIUM STAINED/BLOOD TINGED/FOUL ODOR]
Amount: [SCANT/MODERATE/COPIOUS]
Fetal Heart Rate Post-ROM: [__] bpm
Maternal Temperature: [__] °C/°F
Contraction Pattern Post-ROM: [INCREASED/MAINTAINED/DECREASED]
Client Education: [INFORMED RE: INFECTION RISK, FETAL MONITORING]
Provider Notification: [YES/NO], Time [__]

Newborn initial assessment (APGAR)

Time of Delivery: [__]
Delivery Type: [VAGINAL/CESAREAN]
Infant Sex: [MALE/FEMALE]
Birth Weight: [__] lbs [__] oz
Length: [__] inches
Head Circumference: [__] inches
APGAR Score:
1 Minute: Appearance [__], Pulse [__], Grimace [__], Activity [__], Respiration [__] = __/10
5 Minute: Appearance [__], Pulse [__], Grimace [__], Activity [__], Respiration [__] = __/10
10 Minute: [__]/10 (if needed)
Skin Color: [PINK/PALE/CYANOTIC/JAUNDICED]
Respiratory Effort: [STRONG/WEAK/ABSENT]
Fetal Tone: [GOOD/POOR]
Reflex Irritability: [VIGOROUS/MILD/ABSENT]
Activity: [VIGOROUS/ALERT/LETHARGIC]
Resuscitation: [NONE/STIMULATION/O2/CPAP/INTUBATION]
Abnormalities: [NONE/NOTED: ___]
Mother-Infant Bonding: [EXCELLENT/GOOD/FAIR/NONE YET]

Fetal heart rate strip interpretation

Monitoring Mode: [EXTERNAL / INTERNAL FSE], Toco: [EXTERNAL / IUPC]
Baseline FHR: [__] bpm
Variability: [ABSENT / MINIMAL / MODERATE / MARKED]
Accelerations: [PRESENT — __ x __ bpm x __ sec / ABSENT]
Decelerations: [NONE / EARLY / VARIABLE / LATE / PROLONGED], Depth: [__], Duration: [__]
Category: [I / II / III]
Contractions: frequency q[__] min, duration [__] sec, intensity [MILD/MOD/STRONG] by [PALPATION/MVU __]
Resting Tone: [SOFT / ELEVATED]
Maternal VS: BP [__/__], HR [__], Temp [__], SpO2 [__]%
Interventions: [POSITION CHANGE / IV BOLUS / O2 __ L / D-C PITOCIN / AMNIOINFUSION / NONE]
FHR Response to Intervention: [__]
Provider Notified: [NAME], Time: [__], Response: [__]

Oxytocin infusion titration

Indication: [INDUCTION / AUGMENTATION], Order From: [PROVIDER]
Concentration: [__ units in __ mL], Pump: [SECONDARY LINE, PIGGYBACKED PROXIMAL TO PATIENT]
Start Time: [__], Starting Rate: [__] mU/min
Titration Protocol: increase by [__] mU/min q[__] min to [MAX __]
Current Rate: [__] mU/min, Last Change: [TIME]
Contraction Pattern: q[__] min, [__] sec, [MILD/MOD/STRONG], MVUs [__]
FHR Category: [I/II/III], Baseline [__], Variability [__], Decels [__]
Cervical Exam: [__] cm / [__]% / [__] station, by [NAME], Time [__]
Tachysystole: [NONE / PRESENT — RATE DECREASED OR STOPPED AT TIME __, TERBUTALINE __]
Maternal VS: BP [__/__], HR [__], Temp [__]
I&O: [__] mL in / [__] mL out
Provider Notified of: [__], Time: [__]

Epidural placement and post-placement monitoring

Consent Obtained By: [ANESTHESIA PROVIDER], Time: [__]
Pre-Procedure: BP [__/__], HR [__], FHR baseline [__], IV bolus [__] mL [FLUID] given
Platelet Count: [__], Anticoagulants: [NONE / AGENT, LAST DOSE]
Position During Placement: [SITTING / LATERAL], RN at Bedside Supporting Patient
Placement Time: [__], Level: [__], Attempts: [__]
Infusion: [MEDICATION/CONCENTRATION], Rate: [__] mL/hr, PCEA: [YES/NO]
Post-Placement VS q[__] min x [__]: BP [__/__], HR [__], SpO2 [__]%
FHR After Placement: [CATEGORY / DECELS]
Motor/Sensory Level: [__], Bromage Score: [__]
Pain Before: [0-10], After: [0-10] at [TIME]
Complications: [NONE / HYPOTENSION — TREATED WITH __ / PRURITUS / N-V / HIGH BLOCK]
Safety: bed low, side rails up, fall precautions, foley [PLACED/NOT INDICATED], repositioned q[__]

Postpartum assessment (BUBBLE-LE)

Delivery: [DATE/TIME], Type: [SVD / VACUUM / FORCEPS / CESAREAN], Postpartum Day/Hour: [__]
Breasts: [SOFT / FILLING / ENGORGED], nipples [INTACT / CRACKED], feeding [BREAST / FORMULA / BOTH]
Uterus: fundus [FIRM / BOGGY — MASSAGED], position [MIDLINE / DEVIATED], [__] cm [ABOVE/BELOW] umbilicus
Bladder: voiding [SPONTANEOUSLY], amount [__] mL, [NO] retention, catheter [__]
Bowel: bowel sounds [PRESENT], flatus [YES/NO], BM [DATE]
Lochia: [RUBRA/SEROSA/ALBA], amount [SCANT/SMALL/MODERATE/HEAVY], clots [NONE/__], pad change [TIME]
Episiotomy/Laceration/Incision: [DEGREE/TYPE], REEDA: [__], ice/sitz [APPLIED]
Lower Extremities: [NO] calf tenderness, edema [__], Homan's [NOT ROUTINELY PERFORMED], SCDs [ON]
Emotional Status: [APPROPRIATE / TEARFUL / FLAT], bonding [OBSERVED]
Pain: [0-10], location [__], intervention [__], reassessed [__]
VS: BP [__/__], HR [__], Temp [__], RR [__]
Education: warning signs, perineal care, activity, follow-up [PROVIDED / TEACH-BACK]

Postpartum hemorrhage response

Time Recognized: [__], Recognized By: [__]
Quantitative Blood Loss: [__] mL, Method: [WEIGHED PADS/DRAPES]
Stage: [1 / 2 / 3], Hemorrhage Protocol Activated: [TIME]
Fundus: [BOGGY / FIRM AFTER MASSAGE], Bladder: [EMPTIED — __ mL]
Suspected Etiology: [TONE / TRAUMA / TISSUE / THROMBIN]
VS Trend: BP [__/__] to [__/__], HR [__] to [__], SpO2 [__]%
Access: [__ gauge x __], Labs Sent: [CBC / TYPE AND CROSS / FIBRINOGEN / COAGS], Time [__]
Uterotonics Given: [OXYTOCIN / METHERGINE / HEMABATE / MISOPROSTOL / TXA] — dose/route/time
Interventions: [BIMANUAL MASSAGE / BALLOON TAMPONADE / URETERAL CATH / OR TRANSFER]
Blood Products: [PRODUCT/UNITS/START TIME]
Providers at Bedside: [NAMES/TIMES]
Outcome: [HEMORRHAGE CONTROLLED AT TIME __ / TRANSFERRED TO OR-ICU], Total QBL: [__] mL
Debrief Completed: [YES/NO], Event Report: [FILED]

Newborn transition and initial assessment

Birth Time: [__], GA: [__] weeks, Weight: [__] g, Length: [__] cm, HC: [__] cm
APGAR: 1 min [__], 5 min [__], 10 min [__ / NA]
Resuscitation: [NONE / STIMULATION / PPV / CPAP / INTUBATION / COMPRESSIONS]
Cord: [__] vessels, pH [__ / NOT OBTAINED], delayed clamping [YES/NO]
VS: T [__] [AXILLARY], HR [__], RR [__], SpO2 preductal [__]%
Skin: [PINK / ACROCYANOSIS / MOTTLED], birthmarks [__]
Tone/Activity: [ACTIVE / FLEXED / HYPOTONIC], cry [STRONG/WEAK]
Anterior Fontanel: [SOFT AND FLAT], molding/caput/cephalohematoma: [__]
Skin-to-Skin Initiated: [TIME], Duration: [__], First Feeding: [TIME/TYPE/LATCH QUALITY]
Void: [TIME], Stool: [TIME/CHARACTER]
Medications: vitamin K [DOSE/SITE/TIME], erythromycin ointment [TIME], HepB [GIVEN/DEFERRED]
ID Bands Verified With Mother: [YES], Security Tag Applied: [YES]

OB triage/obstetric evaluation

G[__] P[__], EDD [__], GA [__] weeks by [LMP/US]
Chief Complaint: [CONTRACTIONS / ROM / BLEEDING / DECREASED FETAL MOVEMENT / OTHER]
Onset: [__], Frequency/Duration of Contractions: [__]
Membranes: [INTACT / RUPTURED AT __, FLUID COLOR __, ODOR __], Confirmed By: [POOL/FERN/AMNISURE]
Vaginal Bleeding: [NONE / SPOTTING / AMOUNT]
Fetal Movement: [ACTIVE / DECREASED]
Maternal VS: BP [__/__], HR [__], Temp [__], RR [__], Pain [0-10]
FHR: baseline [__], variability [__], accels [__], decels [__], Category [__]
Cervical Exam: [__] cm / [__]% / [__] station, presentation [__], by [NAME] at [TIME]
Prenatal History: [GBS STATUS / GDM / HTN / PRIOR CESAREAN / OTHER]
Labs: [CBC / UA / GBS / TYPE & SCREEN]
Provider Notified: [NAME], Time: [__]
Disposition: [ADMIT TO L&D / OBSERVATION / DISCHARGE WITH PRECAUTIONS]

Preeclampsia and magnesium sulfate monitoring

Diagnosis: [GESTATIONAL HTN / PREECLAMPSIA WITHOUT SEVERE FEATURES / WITH SEVERE FEATURES / ECLAMPSIA]
BP Trend: [__/__] at [TIME], [__/__] at [TIME], Severe Range Sustained: [YES/NO]
Symptoms: [HEADACHE / VISUAL CHANGES / RUQ PAIN / EDEMA / NONE]
Labs: platelets [__], AST/ALT [__], creatinine [__], protein/creatinine ratio [__]
Antihypertensive Given: [LABETALOL / HYDRALAZINE / NIFEDIPINE] — dose/time, BP after [__/__]
Magnesium Sulfate: loading [__] g over [__], maintenance [__] g/hr, Start Time [__]
DTRs: [__ /4], Clonus: [ABSENT/PRESENT]
Respiratory Rate: [__], SpO2 [__]%, Lung Sounds [CLEAR]
Urine Output: [__] mL/hr (>30 mL/hr [YES/NO]), Foley [PLACED]
Magnesium Level: [__] at [TIME], Calcium Gluconate at Bedside: [YES]
FHR: [CATEGORY], Seizure Precautions: [SUCTION/O2/SIDE RAILS PADDED/LOW STIMULATION]
Provider Notified of: [__], Time: [__]

Pediatric comprehensive assessment

Age/DOB: [__] years [__] months
Weight: [__] kg ([__] lbs), [PLOT ON GROWTH CHART: __TH PERCENTILE]
Height: [__] cm, [__TH PERCENTILE]
Vital Signs: BP [__/__], HR [__], RR [__], Temp [__], Pain [0-10 or FLACC]
General: [ALERT/AWAKE, APPEARS __ YEARS OLD, WELL-NOURISHED/UNDERNOURISHED]
HYDRATION: [WELL-HYDRATED/MILD DEHYDRATION/MODERATE/SEVERE]
Resp: [CLEAR/CRACKLES/WHEEZES], Work of Breathing [NORMAL/INCREASED]
Cardiac: [RRR/IRREGULAR], [NO MURMUR/MURMUR PRESENT]
Abdomen: [SOFT/DISTENDED], [NON-TENDER/TENDER], BS [NORMAL/ABSENT]
Skin: [NO RASH/RASH NOTED AT ___]
Neuro: [APPROPRIATE FOR AGE/DEFICITS]
Mood/Behavior: [HAPPY/IRRITABLE/LETHARGIC/ANXIOUS]
Parent at Bedside: [YES/NO]
Family Coping: [GOOD/ANXIOUS/OVERWHELMED]

Pediatric neurological assessment

Age: [__] years/months
Level of Consciousness: [ALERT/DROWSY/LETHARGIC/UNRESPONSIVE]
Irritability: [NONE/MILD/MODERATE/SEVERE]
Spontaneous Activity: [AGE APPROPRIATE/DECREASED/INCREASED]
Movement: [SYMMETRICAL/ASYMMETRICAL], Strength [GOOD/WEAK/NONE]
Tone: [NORMAL/HYPOTONIC/HYPERTONIC]
Reflexes: [BRISK/NORMAL/DIMINISHED/ABSENT]
Bulging Fontanelle: [FLAT/BULGING/SUNKEN] (if <18 months)
Sutures: [OPEN/CLOSED/FUSED]
Meningeal Signs: [ABSENT/NECK STIFFNESS/KERNING SIGN/BRUDZINSKI]
Seizure Activity: [NONE/DESCRIBED AS ___]
Speech/Cry: [NORMAL/HIGH-PITCHED/WEAK/ABSENT]
Orientation: [AGE APPROPRIATE/DISORIENTED]
Behavior: [NORMAL/IRRITABLE/LETHARGIC/AGITATED]

Pediatric fever management

Temperature: [__] °C/°F, [AXILLARY/ORAL/TYMPANIC/RECTAL]
Time Fever Noted: [__]
Duration: [__ hours/days]
Associated Symptoms: [COUGH/VOMITING/DIARRHEA/RASH/LETHARGY/NONE]
Recent Illness Exposure: [YES/NO], [SPECIFY: ___]
Vaccination Status: [UP TO DATE/BEHIND/UNKNOWN]
Last Antipyretic: [MEDICATION __, DOSE __, TIME __]
Response to Antipyretic: [TEMP DOWN TO __/NO IMPROVEMENT]
Fluid Intake: [ADEQUATE/DECREASED/REFUSING]
Urine Output: [NORMAL/DECREASED]
Appearance: [PLAYFUL/ALERT/LETHARGIC/TOXIC]
Physical Exam: [LIKELY VIRAL/SOURCE NOT APPARENT/POSSIBLE BACTERIAL INFECTION]
Provider Evaluation: [YES/NO]
Orders: [SUPPORTIVE CARE/LABS/IMAGING/ANTIBIOTICS]
Parent Education: [FEVER NORMAL RESPONSE, WHEN TO SEEK CARE]

Pediatric shift assessment with developmental context

Age: [__], Weight: [__] kg (dosing weight), Developmental Level: [__]
Neuro: [ALERT / PLAYFUL / IRRITABLE / LETHARGIC], consolable [YES/NO], fontanel [FLAT / NA]
Respiratory: RR [__], effort [UNLABORED / RETRACTIONS — LOCATION / NASAL FLARING / GRUNTING], lungs [__], SpO2 [__]% on [__]
Cardiac: HR [__], rhythm [__], cap refill [__] sec, pulses [__], color [__]
GI: abdomen [SOFT], bowel sounds [PRESENT], intake [__], emesis [__], stools [NUMBER/CHARACTER]
GU: voiding, [__] wet diapers or [__] mL, [__] mL/kg/hr
Skin: [INTACT], turgor [BRISK], rashes [__], device sites [__]
Pain: [FLACC / WONG-BAKER / NUMERIC] score [__], intervention [__], reassessed [__]
Safety: crib/bed rails up, [ID BAND ON], appropriate [CRIB/BED], choke hazards removed
Caregiver at Bedside: [NAME/RELATIONSHIP], participating in care [YES/NO]
Intake Goal: [__] mL, Actual: [__] mL

Pediatric respiratory distress and bronchiolitis assessment

Age: [__], Weight: [__] kg
Respiratory Rate: [__] (age-appropriate range [__]), SpO2 [__]% on [RA / __ L NC / HFNC __ L]
Work of Breathing: retractions [NONE/SUBCOSTAL/INTERCOSTAL/SUPRACLAVICULAR], nasal flaring [__], grunting [__], head bobbing [__]
Breath Sounds: [CLEAR / WHEEZES / CRACKLES / DIMINISHED], location [__]
Cough: [DRY / WET / PAROXYSMAL], Post-Tussive Emesis: [YES/NO]
Respiratory Score: [__], Trend: [IMPROVED / UNCHANGED / WORSE]
Suctioning: [BULB / NASAL / DEEP], time [__], secretions [AMOUNT/CHARACTER], tolerance [__]
Bronchodilator: [AGENT/DOSE/TIME], pre-treatment score [__], post [__]
Steroids: [AGENT/DOSE/TIME]
Hydration: PO intake [__] mL, IV [__], wet diapers [__], mucous membranes [__]
Feeding Tolerance: [TAKING FULL / DECREASED / NPO FOR WOB]
Provider Notified of: [__], Time: [__]

Pediatric dehydration and rehydration

Weight Today: [__] kg, Baseline Weight: [__] kg, Deficit: [__]%
Dehydration Severity: [MILD / MODERATE / SEVERE]
Mental Status: [ALERT / IRRITABLE / LETHARGIC]
Mucous Membranes: [MOIST / TACKY / DRY], Tears: [PRESENT/ABSENT], Fontanel: [FLAT/SUNKEN/NA]
Skin Turgor: [BRISK / DELAYED], Cap Refill: [__] sec, Extremities: [WARM/COOL]
VS: HR [__], BP [__/__], RR [__], Temp [__]
Ongoing Losses: emesis [__ EPISODES/VOLUME], stools [__ /CHARACTER]
Last Void: [TIME], Wet Diapers Last 24h: [__]
Oral Rehydration: [SOLUTION], [__] mL over [__], tolerance [__]
IV Fluids: [FLUID], bolus [__] mL/kg over [__], maintenance [__] mL/hr
Labs: Na [__], K [__], HCO3 [__], BUN/Cr [__], glucose [__]
Reassessment After Intervention: [__]
Caregiver Education: ORS technique, return precautions, [TEACH-BACK]

Age-appropriate pediatric pain assessment

Age: [__], Scale Used: [FLACC / FACES / NUMERIC / CRIES / N-PASS]
Score: [__], Time: [__]
Behavioral Indicators: [CRYING / GUARDING / GRIMACING / WITHDRAWAL / CONSOLABILITY]
Caregiver Report of Pain Behavior: [__]
Location/Description Per Child: [CHILD'S OWN WORDS]
Suspected Source: [PROCEDURAL / POST-OP / DISEASE-RELATED / UNKNOWN]
Pharmacologic: [AGENT/DOSE mg/kg/ROUTE/TIME]
Non-Pharmacologic: [DISTRACTION / SWADDLING / SUCROSE / POSITIONING / CHILD LIFE / PARENT PRESENCE / HEAT-COLD]
Reassessment Score: [__] at [TIME]
Effectiveness: [ADEQUATE / INADEQUATE — PROVIDER NOTIFIED TIME __]
Caregiver Education: dosing at home, when to call, [TEACH-BACK COMPLETED]

Caregiver education and discharge teaching

Learner: [PARENT / GUARDIAN / PATIENT / BOTH], Name/Relationship: [__]
Preferred Language: [__], Interpreter Used: [NO / YES — ID #]
Learning Barriers: [NONE / LITERACY / EMOTIONAL / COGNITIVE / TIME]
Topics Taught: [DIAGNOSIS / MEDICATION ADMINISTRATION / DEVICE CARE / FEEDING / ACTIVITY / RETURN PRECAUTIONS]
Medication Teaching: name, weight-based dose, measuring device provided [YES/NO], demonstrated [YES/NO]
Method: [VERBAL / WRITTEN / DEMONSTRATION / VIDEO]
Teach-Back Result: [CORRECTLY RESTATED / REQUIRED REINFORCEMENT — REPEATED]
Return Demonstration: [PERFORMED CORRECTLY / NEEDS FOLLOW-UP]
Written Materials Given: [TITLES]
Follow-Up Appointment: [PROVIDER/DATE], Transportation Barrier: [YES/NO]
Questions Answered: [YES], Additional Referrals: [__]

Neonatal assessment and thermoregulation

Corrected GA: [__] weeks, DOL: [__], Weight: [__] g, Change From Birth Weight: [__]%
Temp: [__] [AXILLARY], Environment: [OPEN CRIB / RADIANT WARMER / ISOLETTE — SET TEMP __]
HR: [__], RR: [__], SpO2: [__]% on [__], Apnea/Brady Events: [NUMBER/INTERVENTION]
Respiratory Support: [ROOM AIR / NC __ / CPAP __ / VENT]
Color: [PINK / JAUNDICED — ZONE __ / PALE / MOTTLED], TcB/TSB: [__]
Tone/Activity: [__], NIPS/N-PASS Score: [__]
Feeding: [BREAST / BOTTLE / GAVAGE], volume [__] mL, tolerance [__], residual [__] mL
Voids: [__], Stools: [__/CHARACTER]
Glucose: [__] at [TIME]
Skin: [INTACT], cord [__], devices [__]
Developmental Care: clustered cares, nested positioning, light and noise minimized, kangaroo care [__] min
Parent Involvement: [PRESENT / TAUGHT __ / CALLED]

Psychiatric risk assessment and safety planning

Suicide Risk: [NO RISK/LOW/MODERATE/HIGH/IMMINENT]
Suicidal Ideation: [DENIES/PASSIVE/ACTIVE WITH/WITHOUT PLAN/INTENT]
Plan/Method: [NONE/STATED: ___]
Intent to Harm: [NONE/UNDECIDED/YES]
History of Attempts: [NONE/YES - # ATTEMPTS: __, MOST RECENT: __]
Homicide Risk: [NO RISK/LOW/MODERATE/HIGH]
Thoughts of Harm to Others: [DENIES/PASSIVE/ACTIVE]
Target(s): [NONE/SPECIFIC PERSON(S): ___]
History of Violence: [NONE/YES - DESCRIBE]
Aggressive Behavior This Admission: [NONE/VERBAL/PHYSICAL]
Promotive Factors: [SUBSTANCE USE/STRESSOR/LOSS/ISOLATION/IMPULSIVITY]
Protective Factors: [FAMILY SUPPORT/EMPLOYMENT/SPIRITUALITY/CHILDREN/FUTURE PLANS]
Safety Plan: [SUPP MONITORING/1:1 OBSERVATION/SECLUSION/RESTRAINT]
Provider Evaluation: [ASSESSED/DOCUMENTED: ___]

Psychiatric medication documentation

Current Psychiatric Medications:
Medication Name | Dose | Frequency | Last Given | Route | Indication
[___|___|___|___|___|___]

Side Effects/Tolerability: [NONE/DESCRIBE: ___]
Compliance: [FULL/PARTIAL/NON-COMPLIANT]
Barriers to Compliance: [COST/SIDE EFFECTS/DENIAL/MEMORY/OTHER]
Response to Medication: [EFFECTIVE/PARTIALLY EFFECTIVE/INEFFECTIVE]
PRN Medications Given: [NONE/MEDICATION: __, DOSE: __, TIME: __, REASON: __]
Response to PRN: [EFFECTIVE/PARTIALLY/INEFFECTIVE]
Substance Use: [NONE/DENIES/CURRENT USE: ___]
Drug Screen: [PENDING/NEGATIVE/POSITIVE - SUBSTANCE(S): ___]
Blood Levels: [ORDERED/PENDING/RESULTS: ___]
Monitoring Parameters: [ECG/WEIGHT/GLUCOSE/LIPIDS] - [RESULTS: ___]
Provider Updates: [MEDICATION CHANGE: ___/DOSAGE ADJUSTMENT: ___/NONE]

Behavioral observation and documentation

Mood: [EUTHYMIC/ELEVATED/DEPRESSED/LABILE/ANXIOUS/IRRITABLE]
Affect: [APPROPRIATE/INCONGRUENT/FLAT/BLUNTED/RESTRICTED]
Thought Process: [LOGICAL/COHERENT/TANGENTIAL/LOOSELY ASSOCIATED/INCOHERENT]
Thought Content: [APPROPRIATE/DELUSIONS/PARANOIA/OBSESSIONS/PREOCCUPATIONS]
Perception: [INTACT/HALLUCINATIONS - SPECIFY: ___]
Insight: [GOOD/FAIR/POOR]
Judgment: [GOOD/FAIR/POOR]
Memory: [INTACT/IMPAIRED]
Concentration: [GOOD/FAIR/POOR]
Orienation: [X3/X2/X1/X0]
Speech: [NORMAL/PRESSURED/SLOW/LOUD/QUIET/INCOHERENT]
Psychomotor: [NORMAL/AGITATED/RETARDED]
Behavior During Interaction: [COOPERATIVE/GUARDED/HOSTILE/WITHDRAWN/INAPPROPRIATE]
Interaction with Others: [APPROPRIATE/WITHDRAWN/AGGRESSIVE/SEXUALLY INAPPROPRIATE]
Activities on Unit: [ENGAGED/ISOLATING/SLEEPING EXCESSIVELY/PACING]
Major Behavioral Incidents: [NONE/SPECIFIED: ___]

Suicide and safety risk screening

Screening Tool Used: [C-SSRS / ASQ / OTHER], Time: [__]
Screen Result: [NEGATIVE / POSITIVE — RISK LEVEL __]
Ideation: [DENIES / PASSIVE / ACTIVE], Patient's Own Words: [QUOTE]
Plan: [DENIES / PRESENT — GENERAL DESCRIPTION WITHOUT SPECIFICS]
Intent: [DENIES / PRESENT]
Protective Factors: [FAMILY / FAITH / FUTURE PLANS / TREATMENT ENGAGEMENT / PETS]
Environmental Safety: room searched [TIME], personal belongings [SECURED/INVENTORIED], ligature risks [ADDRESSED]
Observation Level: [ROUTINE Q15 / LINE OF SIGHT / 1:1], Ordered By: [PROVIDER], Started: [TIME]
Safety Plan: [DEVELOPED WITH PATIENT / DECLINED / EXISTING PLAN REVIEWED]
Support Contacts Identified With Patient: [YES/NO]
Provider Notified: [NAME], Time: [__]
Handoff Communicated To: [ONCOMING RN], Time: [__]

Mental status examination

Appearance: [GROOMING / HYGIENE / DRESS / APPARENT AGE]
Behavior: [COOPERATIVE / GUARDED / AGITATED / WITHDRAWN], eye contact [__], psychomotor [NORMAL/RETARDED/AGITATED]
Speech: rate [__], volume [__], [SPONTANEOUS / PRESSURED / IMPOVERISHED]
Mood (patient's words): [QUOTE]
Affect: [FULL / CONSTRICTED / BLUNTED / FLAT / LABILE], congruent with mood [YES/NO]
Thought Process: [LINEAR / CIRCUMSTANTIAL / TANGENTIAL / LOOSE / FLIGHT OF IDEAS]
Thought Content: [NO SI-HI / DELUSIONS — TYPE / OBSESSIONS / PARANOIA]
Perception: [NO AVH / AUDITORY / VISUAL / TACTILE — DESCRIBE PATIENT REPORT]
Cognition: alert, oriented x[__], attention [__], memory [__], concentration [__]
Insight: [GOOD / FAIR / POOR], Judgment: [INTACT / IMPAIRED]
Reliability: [RELIABLE / LIMITED HISTORIAN]

Behavioral escalation and de-escalation intervention

Time of Escalation: [__], Location: [__]
Observed Behavior: [OBJECTIVE DESCRIPTION — NO INTERPRETATION]
Antecedent/Trigger: [IDENTIFIED — DESCRIBE / UNKNOWN]
Risk to Self/Others/Property: [DESCRIBE]
De-Escalation Techniques Used: [LOWERED VOICE / INCREASED SPACE / REDUCED STIMULI / OFFERED CHOICES / ACTIVE LISTENING / REDIRECTION / QUIET ROOM]
Staff Response: [NUMBER RESPONDING / ROLES], Show of Support: [YES/NO]
PRN Offered: [AGENT/DOSE/ROUTE], [ACCEPTED — TIME __ / DECLINED]
Outcome: [DE-ESCALATED AT TIME __ / PROGRESSED TO SECLUSION-RESTRAINT — SEE SEPARATE NOTE]
Behavior at Resolution: [__]
Patient Debrief: [COMPLETED — PATIENT'S PERSPECTIVE / DECLINED]
Staff Debrief: [COMPLETED], Care Plan Updated With: [TRIGGERS / EFFECTIVE STRATEGIES]
Provider Notified: [NAME], Time: [__]

Group therapy participation note

Group Type: [PSYCHOEDUCATION / COPING SKILLS / PROCESS / SUBSTANCE USE / DISCHARGE PLANNING]
Date/Time: [__], Duration: [__] min, Facilitator: [NAME/ROLE]
Topic: [__]
Attendance: [ATTENDED FULL / PARTIAL — LEFT AT __ / DECLINED — REASON]
Participation Level: [ACTIVE / MINIMAL / OBSERVER / DISRUPTIVE]
Content Contributed: [SUMMARY WITHOUT OTHER PATIENTS' IDENTIFIERS]
Affect During Group: [__]
Interaction With Peers: [APPROPRIATE / WITHDRAWN / CONFLICTUAL]
Skills Demonstrated or Practiced: [__]
Insight Demonstrated: [__]
Follow-Up Needed: [1:1 PROCESSING / TREATMENT TEAM DISCUSSION / NONE]

Substance withdrawal monitoring (CIWA/COWS)

Substance: [ALCOHOL / OPIOID / BENZODIAZEPINE / STIMULANT / OTHER]
Last Use: [SUBSTANCE / AMOUNT / ROUTE / DATE-TIME PER PATIENT REPORT]
Scale Used: [CIWA-Ar / COWS], Score: [__], Time: [__], Frequency: q[__]
Score Trend: [__] at [TIME], [__] at [TIME], Direction: [RISING / STABLE / FALLING]
Symptoms Present: [TREMOR / DIAPHORESIS / N-V / ANXIETY / AGITATION / HALLUCINATIONS / GOOSEFLESH / YAWNING / MYDRIASIS]
VS: BP [__/__], HR [__], Temp [__], RR [__]
Medication Given Per Protocol: [AGENT/DOSE/ROUTE/TIME], Response and Rescore: [__] at [TIME]
Seizure Precautions: [IN PLACE], Prior Withdrawal Seizure/DTs: [YES/NO]
Hydration/Nutrition: PO intake [__], thiamine/folate/MVI [GIVEN — TIME]
Orientation: [x__], Hallucinations: [NONE / DESCRIBE]
Provider Notified of: [__], Time: [__]
MOUD/Recovery Resources Discussed: [YES/NO], Patient Response: [__]

Psychotropic medication education and monitoring

Medication: [NAME/DOSE/ROUTE/FREQUENCY], Indication Discussed: [__]
Started/Changed On: [DATE], Reason for Change: [__]
Education Provided: purpose, expected time to effect, common side effects, what to report immediately
Specific Monitoring Discussed: [METABOLIC / AIMS / LITHIUM LEVEL / ANC / EKG-QTc / BP]
AIMS Score: [__ / NOT DUE], Date: [__]
Side Effects Reported by Patient: [NONE / SEDATION / EPS / AKATHISIA / DRY MOUTH / WEIGHT / SEXUAL / OTHER]
Objective Findings: [TREMOR / RIGIDITY / RESTLESSNESS / NONE]
Labs Reviewed: [__], Level: [__], Therapeutic Range Discussed: [YES/NO]
Adherence Barriers Identified: [COST / SIDE EFFECTS / BELIEFS / ACCESS / NONE]
Patient's Stated Willingness to Continue: [__]
Teach-Back: [COMPLETED / REINFORCED]
Provider Notified of: [__]

Seclusion episode documentation

Behavior Necessitating Seclusion: [OBJECTIVE DESCRIPTION OF IMMINENT DANGER]
Less Restrictive Alternatives Attempted: [LIST WITH TIMES AND OUTCOMES]
Seclusion Initiated: [TIME], Room: [__]
Order Obtained: [PROVIDER NAME], Time: [__], Duration Authorized: [__]
Face-to-Face Evaluation: [PROVIDER/QUALIFIED STAFF], Time: [__] (within 1 hour)
Continuous Observation By: [STAFF NAME], Documented q[__] min
Patient Status at Intervals: behavior [__], VS [__], hydration/toileting offered [TIME], comfort needs [__]
Items Removed From Patient/Room: [LIST]
Release Criteria Explained to Patient: [YES/NO], Criteria: [__]
Seclusion Ended: [TIME], Total Duration: [__]
Patient Debrief: [COMPLETED — SUMMARY / DECLINED]
Staff Debrief and Care Plan Update: [COMPLETED], Preventive Strategies Added: [__]
Family/Guardian Notified: [YES/NO/NA], Event Report: [FILED]

Surgical safety checklist (WHO timeout)

SURGICAL SAFETY CHECKLIST - TIME OUT
Date/Time: [__]
Surgeon: [__], Anesthesia: [__], Circulating RN: [__], Scrub Tech: [__]

SIGN IN (Before Anesthesia Induction):
- Patient confirmed identity: [YES/NO]
- Site marked: [YES/NO/N/A]
- Anesthesia machine/medication check complete: [YES/NO]
- Pulse oximeter functioning: [YES/NO]
- Known allergies: [NKDA/LIST]
- Difficult airway/aspiration risk: [NO/YES - EQUIPMENT AVAILABLE]
- Significant blood loss risk >500mL: [NO/YES - IV/FLUIDS PLANNED]

TIME OUT (Before Incision):
- All team members introduced: [YES]
- Patient identity, site, procedure confirmed: [YES]
- Antibiotic prophylaxis given within 60 min: [YES/NO/N/A]
- Anticipated critical events reviewed: [YES]
- Imaging displayed: [YES/NO/N/A]

SIGN OUT (Before Patient Leaves OR):
- Procedure recorded: [YES]
- Instrument/sponge/needle count correct: [YES/NO - DISCREPANCY NOTED]
- Specimen labeled: [YES/NO/N/A]
- Equipment issues to be addressed: [NONE/NOTED: ___]
- Key concerns for recovery: [___]

Pre-operative nursing assessment

Pre-Operative Assessment
Date/Time: [__]
Surgery: [PROCEDURE]
Scheduled Time: [__]
Patient: [NAME], DOB: [__], MRN: [__]
Vital Signs: BP [__/__], HR [__], RR [__], Temp [__], SpO2 [__]%
Height: [__], Weight: [__ kg/lbs], BMI: [__]
Allergies: [NKDA / LIST WITH REACTIONS]
Consents Signed: [YES/NO - MISSING: ___]
NPO Status: [YES - SINCE __/NOT CLEARED]
Last Intake: [TIME: __, TYPE: ___]
Preop Medications Given: [NONE/LIST WITH TIME]
IV Access: [SIZE: __, LOCATION: __]
Labs/Results Reviewed: [YES/NO - PENDING: ___]
Type & Screen/Crossmatch: [COMPLETED/N/A]
Pregnancy Test: [NEGATIVE/POSITIVE/N/A/PENDING]
Medical Devices: [NONE/PACEMAKER/COCHLEAR IMPLANT/OTHER: ___]
Patient Understanding: [VERBALIZES UNDERSTANDING OF PROCEDURE/QUESTIONS ANSWERED]
Anxiety Level: [CALM/MILDLY ANXIOUS/VERY ANXIOUS]
Family Present: [YES/NO]
Next of Kin Notified: [YES/NO]

Intraoperative circulating nurse documentation

Intraoperative Circulating Nurse Note
Date: [__]
Procedure: [___]
Surgeon: [__], Assistant: [__], Anesthesia Type: [GENERAL/REGIONAL/SPINAL/MAC]
Anesthesiologist/CRNA: [__]
Circulating RN: [__], Scrub Tech/RN: [__]
Patient Position: [SUPINE/PRONE/LATERAL/LITHOTOMY/OTHER: ___]
Positioning Aids: [PADDING AT: ___]
Skin Prep: [BETADINE/CHLORHEXIDINE/OTHER: ___]
Draping: [STANDARD/CUSTOM: ___]
Electrosurgery: [BOVIE/BIPOLAR/BOTH], Pad Location: [___]
Antibiotic Given: [NAME, DOSE, TIME]
Sponge Count: [CORRECT at START/CLOSURE/FINAL]
Instrument Count: [CORRECT at START/CLOSURE/FINAL]
Needle Count: [CORRECT at START/CLOSURE/FINAL]
Blood Loss (estimated): [__ mL]
Urine Output: [__ mL]
IV Fluids Infused: [__ mL, TYPE: ___]
Specimen(s) Collected: [NONE/TYPE: ___, LABELED: YES]
Intraoperative Events: [NONE/DESCRIBE: ___]
Case Duration: [__ minutes]
End of Case Status: [STABLE/UNSTABLE]

Surgical safety checklist and time-out

Sign-In (Before Induction): patient identity, procedure, site marked [YES/NA], consent verified, allergies, airway risk, aspiration risk, blood loss risk reviewed
Time-Out (Before Incision): Time [__], All Activity Stopped, Led By [ROLE]
  Correct Patient: [VERIFIED], Correct Procedure: [VERIFIED], Correct Site/Side: [VERIFIED]
  Antibiotic Prophylaxis: [AGENT/DOSE], Given at [TIME] (within 60 min)
  VTE Prophylaxis: [SCDs APPLIED / ANTICOAGULANT]
  Imaging Displayed: [YES/NA]
  Anticipated Critical Events: surgeon [__], anesthesia [__], nursing [__]
  Implants/Special Equipment Available: [__]
  Fire Risk Assessment Score: [__], Mitigation: [__]
Team Members Present and Introduced: [ROLES]
Sign-Out (Before Patient Leaves): procedure recorded, counts correct [YES/NO], specimens labeled and read back, equipment issues [__], recovery concerns [__]

Surgical count documentation

Counts Performed By: [SCRUB NAME] and [CIRCULATOR NAME]
Initial Count: [TIME], Items: sponges [__], sharps [__], instruments [__], miscellaneous [__]
Additional Items Added During Case: [ITEM/COUNT/TIME]
First Closing Count: [TIME], Result: [CORRECT / INCORRECT]
Final Count: [TIME], Result: [CORRECT / INCORRECT]
If Incorrect: surgeon notified [TIME], search performed [AREAS], X-ray obtained [TIME/RESULT], resolution [__]
Radiopaque Items Used: [YES/NO]
Items Intentionally Retained: [NONE / ITEM AND SURGEON DIRECTIVE, DOCUMENTED]
Count Sheet Completed and Signed: [YES]
Event Report if Discrepancy: [FILED / NA]

Intraoperative positioning and skin protection

Position: [SUPINE / PRONE / LATERAL — SIDE / LITHOTOMY / BEACH CHAIR / TRENDELENBURG]
Positioned By: [NAMES/ROLES], Time: [__]
Devices Used: [GEL PADS / FOAM / ARM BOARDS <90 DEGREES / STIRRUPS / BEAN BAG / HEAD REST / SAFETY STRAP]
Pressure Points Padded: [HEELS / SACRUM / ELBOWS / OCCIPUT / KNEES / ANKLES / FACE]
Eyes: [TAPED / LUBRICATED / PROTECTED], Ears/Nose Free of Pressure: [VERIFIED]
Extremity Alignment: neutral, no hyperextension, brachial plexus protected
Skin Assessment Pre-Op: [INTACT / DESCRIBE], Post-Op: [INTACT / DESCRIBE]
Electrosurgical Dispersive Pad: site [__], skin [INTACT BEFORE AND AFTER]
SCDs/TEDs: [APPLIED — TIME]
Warming Device: [TYPE/SETTING], Temp Monitoring: [__]
Position Changes During Case: [NONE / TIME AND TYPE]
Total Time in Position: [__]

Surgical specimen handling and chain of custody

Specimen #: [__] of [__]
Source/Site: [ANATOMIC SITE AS STATED BY SURGEON], Laterality: [__]
Type: [BIOPSY / EXCISION / FROZEN SECTION / CULTURE / CYTOLOGY]
Surgeon Verbal Identification: [STATED], Read Back by Circulator: [CONFIRMED], Time: [__]
Preservative: [FORMALIN / SALINE / FRESH / NONE], Container Labeled at Bedside: [YES]
Label Contains: patient name, MRN, DOB, source, date/time, surgeon
Frozen Section: sent [TIME], result received [TIME], result [__], communicated to surgeon [TIME]
Special Handling: [ORIENTATION SUTURES / MARGINS MARKED / DO NOT BISECT]
Transported By: [NAME], Time: [__], Received By Lab: [NAME/TIME]
Requisition Completed: [YES], Discrepancies: [NONE / DESCRIBE]

OR to PACU handoff report

Patient: [NAME/MRN/AGE], Allergies: [__]
Procedure Performed: [__], Surgeon: [__], Anesthesia Type: [GENERAL / MAC / REGIONAL / SPINAL]
Start/End Time: [__], Anesthesia Provider: [__]
Airway: [EXTUBATED / LMA REMOVED / INTUBATED — SETTINGS]
Hemodynamics Intraop: BP range [__], HR range [__], events [NONE/DESCRIBE]
Estimated Blood Loss: [__] mL, Urine Output: [__] mL, Fluids Given: [TYPE/VOLUME], Blood Products: [__]
Medications Given: [ANTIBIOTICS / ANTIEMETICS / OPIOIDS / REVERSAL — DOSE AND TIME]
Lines/Drains/Tubes: [TYPE/SITE/OUTPUT]
Dressings: [LOCATION/CONDITION], Packing: [YES/NO — REMOVAL PLAN]
Weight-Bearing/Activity Restrictions: [__]
Positioning/Skin Concerns: [__]
Post-Op Orders and Concerns: [PAIN PLAN / MONITORING / SURGEON PREFERENCES]
Report Given To: [PACU RN NAME], Time: [__], Questions Answered: [YES]

Telemetry comprehensive shift assessment

Telemetry Shift Assessment
Date/Time: [__]
Monitor Lead: [LEAD II/V1/MCL1]
Current Rhythm: [NSR/AFIB/AFLUTTER/SVT/VT/OTHER: ___]
HR: [__] bpm, [REGULAR/IRREGULAR]
PR Interval: [__ ms, NORMAL <200ms/PROLONGED]
QRS Duration: [__ ms, NORMAL <120ms/WIDE]
QT/QTc: [__ / __ ms, NORMAL/PROLONGED]
Vital Signs: BP [__/__], RR [__], Temp [__], O2 [__]%
O2 Source: [ROOM AIR/O2 via ___ at __ L/min]
Chest Pain: [NONE/PRESENT - describe: ___]
Palpitations: [NONE/PRESENT]
Dyspnea: [NONE/MILD/MODERATE/SEVERE]
Edema: [NONE/MILD/MODERATE pitting - location: ___]
IV Access: [LOCATION: ___], [PATENT/SLUGGISH]
Cardiac Meds: [LIST CURRENT DRIPS/MEDS]
Last 12-Lead: [DATE/TIME: ___]
Provider Notification: [NOT NEEDED/YES - RE: ___]

Cardiac rhythm strip interpretation

Rhythm Strip Interpretation
Date/Time: [__]
Lead Monitored: [LEAD II/V1/MCL1/OTHER: ___]
Rate: [__] bpm
Rhythm: [REGULAR/REGULARLY IRREGULAR/IRREGULARLY IRREGULAR]
P Waves: [PRESENT/ABSENT/FLUTTER WAVES/FIBRILLATORY]
P Wave Morphology: [UPRIGHT IN II/INVERTED/NOTCHED/OTHER]
PR Interval: [__ ms] - [NORMAL 120-200ms/SHORT/PROLONGED/VARIABLE]
QRS Complex: [NARROW <120ms/WIDE ≥120ms]
QRS Morphology: [NORMAL/LBBB/RBBB/ABERRANT/DELTA WAVE]
ST Segment: [ISOELECTRIC/ELEVATION AT ___/DEPRESSION AT ___]
T Waves: [UPRIGHT/INVERTED/PEAKED/FLATTENED]
QT/QTc: [__ / __ ms] - [NORMAL/PROLONGED >500ms]
Interpretation: [NSR/SINUS TACH/SINUS BRADY/AFIB/AFLUTTER/SVT/PVCs/VT/VF/PACED/OTHER: ___]
Change from Previous: [NO CHANGE/NEW FINDING: ___]
Provider Notified: [YES - TIME: __/NOT INDICATED]

Telemetry cardiac medication check

Cardiac Medication Safety Check
Date/Time: [__]
Patient Weight: [__ kg]
Allergies: [NKDA / LIST]
Current Cardiac Meds:
- Antiarrhythmic: [AMIODARONE/METOPROLOL/DILTIAZEM/DIGOXIN/FLECAINIDE/OTHER: ___]
- Anticoagulant: [HEPARIN/WARFARIN/APIXABAN/RIVAROXABAN/NONE]
- Diuretics: [FUROSEMIDE/SPIRONOLACTONE/OTHER/NONE]
QTc Before Dose: [__ ms]
HR Before Dose: [__] bpm
BP Before Dose: [__/__]
Hold Parameters Met: [YES - HOLD/NO - GIVE]
Hold Reason (if applicable): [HR <__ / BP <__ / QTc >__]
Medication Given: [YES - TIME: __/HELD - PROVIDER NOTIFIED: __]
Repeat ECG Needed: [YES - DUE: __/NO]
Patient Education Provided: [YES/NO]

Telemetry rhythm change notification

Rhythm Change Notification - SBAR
SITUATION:
Patient: [NAME, ROOM #], Time: [__]
New Rhythm: [DESCRIBE]
Vital Signs: BP [__/__], HR [__], O2 [__]%
Symptoms: [ASYMPTOMATIC/CHEST PAIN/DYSPNEA/DIAPHORESIS/DIZZINESS/SYNCOPE]

BACKGROUND:
Baseline Rhythm: [PREVIOUS RHYTHM]
Time of Change: [__]
Duration of New Rhythm: [__ minutes/ongoing]
Relevant History: [CARDIAC Hx, MEDS, ALLERGIES]
Last 12-Lead: [DATE/TIME]
Last K+ / Mg+: [VALUES/PENDING]

ASSESSMENT:
Clinical Impression: [STABLE/UNSTABLE/DETERIORATING]
Hemodynamically: [STABLE/COMPROMISED]

RECOMMENDATION:
Requested Action: [12-LEAD ECG/LABS/MEDICATION CHANGE/EVALUATION AT BEDSIDE/TRANSFER]
Urgency: [ROUTINE/SOON/STAT/CODE CALLED]
I am calling from: [UNIT/PHONE #]

Heart failure daily assessment

Weight Today: [__] lbs/kg, Yesterday: [__], Change: [__], Same Scale/Time/Clothing: [YES]
Ejection Fraction: [__]%, HF Type: [HFrEF / HFpEF], NYHA Class: [__]
Respiratory: RR [__], SpO2 [__]% on [__], lungs [CLEAR / CRACKLES — LEVEL], orthopnea [__ PILLOWS], PND [YES/NO]
Cardiac: HR [__], rhythm [__], heart sounds [S1S2 / S3 / MURMUR], JVD [__] cm
Edema: location [__], severity [1+ TO 4+], pitting [YES/NO]
Perfusion: extremities [WARM/COOL], cap refill [__] sec, mentation [__]
I&O: intake [__] mL, output [__] mL, net [__], fluid restriction [__] mL, adherence [__]
Diuretic: [AGENT/DOSE/ROUTE/TIME], response [__] mL over [__] hrs
Labs: BNP/NT-proBNP [__], K [__], Mg [__], creatinine [__], sodium [__]
Activity Tolerance: [__], Symptoms With Exertion: [__]
Education Reinforced: daily weights, sodium limit, fluid restriction, when to call, medication adherence
Provider Notified of: [__], Time: [__]

Anticoagulation monitoring and bleeding assessment

Agent: [HEPARIN DRIP / ENOXAPARIN / WARFARIN / DOAC — NAME], Dose/Rate: [__]
Indication: [AFIB / VTE / ACS / MECHANICAL VALVE / OTHER]
Labs: [aPTT / ANTI-XA / INR / PLATELETS], Result: [__], Time Drawn: [__]
Therapeutic Range: [__], Status: [THERAPEUTIC / SUBTHERAPEUTIC / SUPRATHERAPEUTIC]
Rate Adjustment Per Protocol: [FROM __ TO __], Time: [__], Bolus: [GIVEN/HELD]
Bleeding Assessment: gums [__], stool [COLOR/GUAIAC], urine [__], IV sites [__], bruising [__], neuro changes [NONE]
Hemoglobin/Hematocrit: [__] / [__], Trend: [STABLE / FALLING]
HIT Risk: platelet count [__], trend [__], 4T score [__ / NOT INDICATED]
Held For: [PROCEDURE / BLEEDING / LAB], Time Held: [__], Restart Plan: [__]
Reversal Agent Available: [PROTAMINE / VITAMIN K / ANDEXANET / IDARUCIZUMAB / NA]
Patient Education: bleeding precautions, drug-food interactions, follow-up labs, [TEACH-BACK]
Provider Notified of: [__], Time: [__]

Inpatient chest pain event

Time of Onset: [__], Reported By: [PATIENT / OBSERVED]
Description: [PRESSURE / SHARP / BURNING], Location: [__], Radiation: [__], Severity: [0-10]
Associated Symptoms: [DIAPHORESIS / NAUSEA / DYSPNEA / DIZZINESS]
Activity at Onset: [REST / EXERTION / POST-MEAL]
VS: BP [__/__] (both arms if indicated), HR [__], RR [__], SpO2 [__]%, Temp [__]
Telemetry Rhythm at Onset: [__], ST Changes on Monitor: [YES/NO]
12-Lead EKG: obtained [TIME], compared to prior [YES], findings [__]
Interventions: O2 [__ L IF SpO2 <90%], ASA [DOSE/TIME], nitroglycerin [DOSE/TIME/BP AFTER], morphine [__]
Pain After Each Intervention: [0-10 AT TIME]
Labs: troponin [TIME/RESULT], serial [TIME/RESULT]
Provider Notified: [NAME], Time: [__], Orders Received: [__]
Outcome: [RESOLVED AT TIME __ / ONGOING / TRANSFERRED TO __]

Post-cardiac catheterization or device implant care

Procedure: [DIAGNOSTIC CATH / PCI WITH STENT / EP STUDY / ABLATION / PACEMAKER / ICD], Time Completed: [__]
Access Site: [RADIAL / FEMORAL — SIDE], Sheath: [REMOVED AT __ / IN PLACE], Closure Device: [__]
Site Assessment: [DRY AND INTACT / OOZING / HEMATOMA __ cm / BRUIT], Time Checked: [__]
Distal Pulses: [PRESENT/DOPPLER], Extremity: [WARM / COOL], Sensation/Movement: [INTACT]
Bed Rest: [__] hrs, HOB [__] degrees, affected extremity straight, Start: [__], End: [__]
VS/Site Checks: q[__] min x [__], then q[__]
VS: BP [__/__], HR [__], rhythm [__], SpO2 [__]%
Pain at Site: [0-10], back pain [__]
Hydration: IV [FLUID/RATE], PO encouraged, UOP [__] mL, creatinine [__] (contrast)
Antiplatelets: [AGENT/DOSE/TIME], critical to continue [EDUCATED]
Device-Specific: arm sling [__], incision [__], device interrogation [__], restrictions taught
Complications: [NONE / DESCRIBE], Provider Notified: [__]

Pacemaker and ICD function assessment

Device: [PERMANENT PACEMAKER / ICD / CRT / TEMPORARY TRANSVENOUS / EPICARDIAL WIRES]
Mode: [__], Set Rate: [__], Output: [__] mA, Sensitivity: [__] mV
Underlying Rhythm: [__], Intrinsic Rate: [__]
Pacing Spikes Present: [ATRIAL / VENTRICULAR / BOTH]
Capture: [100% / INTERMITTENT FAILURE TO CAPTURE — DESCRIBE]
Sensing: [APPROPRIATE / UNDERSENSING / OVERSENSING]
Patient Symptoms: [ASYMPTOMATIC / DIZZINESS / SYNCOPE / PALPITATIONS / HICCUPS]
VS: HR [__], BP [__/__], perfusion [__]
ICD Therapies Delivered: [NONE / ATP / SHOCK — NUMBER AND TIMES], Patient Response: [__]
Insertion Site: [CDI / DRAINAGE / HEMATOMA], Arm Restrictions Maintained: [YES]
Magnet Available at Bedside: [YES / NA], Backup Pacing Equipment: [AVAILABLE]
Provider/EP Notified of: [__], Time: [__]
Education: site care, arm restrictions, magnet safety, when to call, ID card, [TEACH-BACK]

Outpatient initial visit assessment

Outpatient Visit Assessment
Date: [__], Provider: [__]
Visit Type: [NEW PATIENT/ESTABLISHED/URGENT/WELLNESS]
Chief Complaint: [CC]
History of Present Illness: [ONSET, DURATION, QUALITY, SEVERITY, TIMING, CONTEXT, MODIFYING FACTORS, ASSOCIATED SYMPTOMS]
Review of Systems: [PERTINENT POSITIVES/NEGATIVES]
Allergies: [NKDA / LIST WITH REACTIONS]
Current Medications: [LIST MEDICATIONS WITH DOSES]
Active Problem List: [LIST]
Social History: [TOBACCO/ALCOHOL/DRUGS/MARITAL STATUS/OCCUPATION/EXERCISE]
Family History: [PERTINENT]
Vital Signs: BP [__/__], HR [__], RR [__], Temp [__], SpO2 [__]%, Weight [__ lbs/kg], BMI [__]
Height: [__ inches]
Pain Level: [0-10]
General Appearance: [WELL-APPEARING/ILL-APPEARING, ALERT, NO ACUTE DISTRESS]
Physical Exam: [PERTINENT FINDINGS]
Assessment: [DIAGNOSIS/PROBLEM]
Plan: [MEDICATIONS/REFERRALS/LABS/IMAGING/FOLLOW-UP INSTRUCTIONS]
Patient Education: [TOPICS COVERED]
Return Precautions: [FEVER/WORSENING SYMPTOMS/SPECIFIC CONCERNS]
Follow-up: [DATE/TIME or PRN]

Outpatient vital signs and intake

Outpatient Intake Note
Date/Time: [__]
Triage RN: [__]
Vital Signs:
- BP: [__/__] (L/R arm, seated/standing)
- HR: [__] bpm, [Regular/Irregular]
- RR: [__] /min
- Temp: [__] °C/°F ([Oral/Axillary/Tympanic])
- SpO2: [__]% on [Room Air/O2 __ L/min]
- Weight: [__] lbs / [__] kg
- Height: [__] ft [__] in / [__] cm
- BMI: [__]
Orthostatic Vitals (if indicated):
- Supine BP [__/__], HR [__]
- Standing BP [__/__], HR [__]
Pain: [0-10], Location [___]
Allergies Verified: [YES - NO CHANGES/YES - UPDATED: ___]
Medication List Reviewed: [YES - NO CHANGES/YES - CHANGES: ___]
Chief Complaint: [___]
Last Menstrual Period (if applicable): [__]
Smoke/Alcohol/Drug Use Screened: [YES - NEGATIVE/YES - POSITIVE: ___]
Advance Directive on File: [YES/NO/PATIENT DECLINES]

Follow-up visit note

Follow-Up Visit Note
Date: [__], Last Visit: [__]
Reason for Follow-up: [___]
Interval History Since Last Visit:
- Symptoms: [IMPROVED/UNCHANGED/WORSENED]
- New Symptoms: [NONE/DESCRIBE: ___]
- ER/Urgent Care Visits Since Last Visit: [NONE/YES - DATE/REASON: ___]
- Hospitalization Since Last Visit: [NONE/YES - DATE/REASON: ___]
Medication Compliance: [COMPLIANT/PARTIALLY COMPLIANT/NON-COMPLIANT]
Side Effects Reported: [NONE/DESCRIBE: ___]
Labs/Imaging Results Reviewed: [YES - RESULTS: ___/PENDING]
Vital Signs: BP [__/__], HR [__], Temp [__], SpO2 [__]%, Weight [__]
Weight Change: [NONE/GAINED __ lbs/LOST __ lbs since last visit]
Physical Exam: [PERTINENT FINDINGS]
Assessment: [STABLE/IMPROVED/WORSENED]
Plan Adjustments: [NO CHANGES/MEDICATION CHANGE: ___/NEW REFERRAL: ___/NEW LAB: ___]
Patient Goals: [DISCUSSED/REVISED: ___]
Patient Questions Addressed: [YES/NO - DETAILS: ___]
Return Visit: [__ weeks/months or PRN]

Patient education documentation

Patient Education Documentation
Date: [__], Educator: [__]
Topics Covered:
- Diagnosis: [DIAGNOSIS EXPLAINED - YES/NO]
- Medications: [NAME, PURPOSE, DOSE, SCHEDULE, SIDE EFFECTS - YES/NO]
- Diet/Nutrition: [SPECIFIC RECOMMENDATIONS - YES/NO]
- Activity/Exercise: [RESTRICTIONS/RECOMMENDATIONS - YES/NO]
- Wound Care: [INSTRUCTIONS PROVIDED - YES/NO/N/A]
- Disease Management: [SELF-MONITORING/SIGNS OF WORSENING - YES/NO]
- When to Seek Care: [EMERGENCY SYMPTOMS REVIEWED - YES/NO]
Education Method: [VERBAL/WRITTEN/DEMONSTRATION/VIDEO/INTERPRETER USED]
Language: [ENGLISH/SPANISH/OTHER: ___]
Literacy Level Assessed: [YES/NO]
Health Literacy Concerns: [NONE/NOTED: ___]
Barriers to Learning: [NONE/LANGUAGE/ANXIETY/COGNITIVE/HEARING/VISION]
Patient Response: [VERBALIZES UNDERSTANDING/DEMONSTRATED BACK/QUESTIONS ANSWERED]
Return Demonstration: [NOT REQUIRED/COMPLETED SUCCESSFULLY/NEEDS REINFORCEMENT]
Caregiver Included: [YES/NO]
Written Materials Provided: [YES - SPECIFY: ___/NO]
Follow-up Education Needed: [YES - TOPIC: ___/NO]

Telephone triage encounter

Call Received: [DATE/TIME], Caller: [PATIENT / PARENT / CAREGIVER — NAME/RELATIONSHIP]
Callback Number Verified: [YES]
Chief Complaint in Caller's Words: [QUOTE]
Onset/Duration: [__], Severity: [__], Associated Symptoms: [__]
Relevant History/Medications/Allergies: [__]
Red Flag Symptoms Screened: [CHEST PAIN / SOB / NEURO CHANGE / UNCONTROLLED BLEEDING / SUICIDAL IDEATION] — [PRESENT/ABSENT]
Protocol Used: [PROTOCOL NAME/VERSION]
Disposition Per Protocol: [911 / ED NOW / URGENT CARE / APPOINTMENT WITHIN __ / HOME CARE]
Disposition Given: [__], Caller Agreement: [YES / DECLINED — ADVISED OF RISK, DOCUMENTED]
Home Care Advice Given: [__]
Return/Escalation Precautions: [SPECIFIC SYMPTOMS]
Provider Consulted: [NAME/TIME / NOT REQUIRED BY PROTOCOL]
Follow-Up Call Scheduled: [YES — TIME / NO]

Immunization administration record

Vaccine: [NAME], Manufacturer: [__], Lot #: [__], Expiration: [__]
Dose: [__] mL, Route: [IM / SC / INTRANASAL / ORAL], Site: [__]
Administered By: [NAME/CREDENTIALS], Date/Time: [__]
Series: dose [__] of [__], Next Dose Due: [DATE]
VIS Given: [VACCINE NAME], VIS Edition Date: [__], Provided to: [PATIENT/PARENT], Time: [__]
Screening Completed: current illness, allergies to vaccine components, prior reactions, immunocompromise, pregnancy [AS APPLICABLE]
Contraindications/Precautions: [NONE IDENTIFIED / DESCRIBE]
Consent: [VERBAL / WRITTEN], Obtained From: [__]
Post-Vaccination Observation: [15 / 30] min, Reaction: [NONE / DESCRIBE]
Aftercare Education: soreness, fever management, when to call
Entered Into State Immunization Registry: [YES/NO]

Chronic disease management visit

Condition(s) Addressed: [__]
Self-Management Since Last Visit: [__]
Home Monitoring Data Reviewed: [BP LOG / GLUCOSE LOG / WEIGHT / PEAK FLOW], Values: [RANGE]
Today's Measurements: BP [__/__], HR [__], weight [__], BMI [__], glucose/A1c [__]
Medication Adherence: [TAKING AS PRESCRIBED / MISSED DOSES — FREQUENCY AND BARRIER]
Barriers Identified: [COST / SIDE EFFECTS / COMPLEXITY / TRANSPORTATION / HEALTH LITERACY / FOOD INSECURITY]
Symptoms/Exacerbations Since Last Visit: [__]
Preventive Care Due: [LABS / EYE EXAM / FOOT EXAM / SCREENINGS / VACCINES] — [ORDERED / SCHEDULED]
Goal Set With Patient This Visit: [PATIENT'S OWN GOAL, SPECIFIC AND MEASURABLE]
Education Provided: [TOPICS], Method: [__], Teach-Back: [COMPLETED]
Referrals Placed: [__]
Follow-Up: [INTERVAL], Next Contact: [DATE / METHOD]

Pre-procedure phone screening and instructions

Procedure Scheduled: [__], Date/Time: [__], Location: [__]
Call Completed: [DATE/TIME], Spoke With: [PATIENT / DESIGNATED CONTACT]
NPO Instructions Given: nothing after [TIME], clear liquids until [TIME]
Medication Instructions: hold [AGENTS AND DURATION], take with sip of water [AGENTS]
Anticoagulant/Antiplatelet Hold Instructions Confirmed With Provider: [YES], Instructions: [__]
Diabetes Medication Instructions: [__], Glucose Monitoring Plan: [__]
Bowel Prep: [PRODUCT/TIMING], Instructions Reviewed: [YES/NA]
Allergies/Prior Anesthesia Reactions: [__]
Responsible Adult Driver Confirmed: [NAME/RELATIONSHIP], Patient Aware Procedure Cancelled Without One: [YES]
Arrival Time and Location Confirmed: [__]
What to Bring/Wear Reviewed: [__]
Questions Answered: [__], Teach-Back Completed: [YES]
Barriers to Attendance: [NONE / TRANSPORTATION / WORK / CHILDCARE], Resolution: [__]

Outpatient infusion visit documentation

Medication: [NAME/DOSE], Indication: [__], Cycle/Visit #: [__]
Pre-Infusion Labs Reviewed: [CBC / CMP / OTHER], Values Within Parameters: [YES/NO — PROVIDER NOTIFIED]
Order Verified: [PROVIDER], Two-RN Verification (if required): [NAME/TIME]
Access: [PERIPHERAL — SITE/GAUGE / PORT — ACCESSED WITH __ NEEDLE, BLOOD RETURN PRESENT / PICC]
Pre-Medications: [AGENT/DOSE/TIME]
Baseline VS: BP [__/__], HR [__], RR [__], Temp [__], SpO2 [__]%
Infusion Start: [TIME], Rate: [__], Titration Schedule: [__]
VS During: [TIME/VALUES]
Infusion Reaction: [NONE / DESCRIBE — INFUSION STOPPED TIME __, TREATMENT GIVEN, PROVIDER NOTIFIED]
Infusion Complete: [TIME], Total Volume: [__] mL, Flush: [__]
Access Removed/Deaccessed: [TIME], Site: [__], Dressing: [__]
Post-Infusion VS and Status: [__]
Discharge Education and Next Appointment: [__]

Missed appointment and outreach documentation

Appointment Date/Time Missed: [__], Provider: [__], Visit Type: [__]
No-Show/Late Cancellation: [__]
Outreach Attempt 1: [DATE/TIME], Method: [PHONE / PORTAL / TEXT / MAIL], Outcome: [REACHED / VOICEMAIL / NO ANSWER]
Outreach Attempt 2: [DATE/TIME], Method: [__], Outcome: [__]
Patient-Reported Barrier: [TRANSPORTATION / WORK / CHILDCARE / COST / FORGOT / SYMPTOMS RESOLVED / OTHER]
Clinical Risk of Missed Visit: [LOW / MODERATE / HIGH — RATIONALE]
Urgent Follow-Up Needs: [ABNORMAL RESULTS PENDING REVIEW / MEDICATION REFILL / POST-HOSPITAL FOLLOW-UP]
Provider Notified: [NAME/TIME / NOT REQUIRED]
Rescheduled: [DATE/TIME] or [PATIENT DECLINED / UNABLE TO REACH]
Resources Offered: [TRANSPORTATION / TELEHEALTH / EXTENDED HOURS / FINANCIAL COUNSELING]
Letter Sent: [DATE / NA]

Quick vital signs assessment

Time: [__]
BP: [__/__] (Location: L ARM / R ARM / BOTH)
HR: [__] (Regular/Irregular)
RR: [__] (Unlabored/Labored)
Temp: [__] °C/°F (Axillary/Oral/Tympanic)
O2 Sat: [__]% (Room Air / O2 via ___)
Pain Level: [0-10]
Pain Location: [___]
General Appearance: [Alert/Oriented/Comfortable/Distressed]
Skin: [Warm/Cool/Dry/Diaphoretic/Pale/Flushed]
Speech: [Clear/Slurred/Other]
Response to Stimulation: [Appropriate/Delayed/Minimal]

SBAR handoff template

SITUATION:
Patient Name: [___], Room: [___], Time: [___]
Current Issue: [___]
Vital Signs: BP [__/__], HR [__], RR [__], Temp [__], O2 [__]%

BACKGROUND:
Admitting Diagnosis: [___]
Relevant History: [Allergies: ___, PMHx: ___, Recent Changes: ___]

ASSESSMENT:
Current Status: [Stable/Unstable/Declining]
Key Findings: [___]

RECOMMENDATION:
What Needs to Happen: [___]
Urgency Level: [Routine/Soon/STAT]
Provider to Contact: [Name and Contact]

Universal pain assessment

Pain Level: [0-10]
Location: [Specific anatomical location]
Onset: [When did pain start?]
Duration: [Continuous/Intermittent]
Character: [Sharp/Dull/Aching/Burning/Throbbing]
Aggravating Factors: [What makes it worse?]
Relieving Factors: [What helps?]
Associated Symptoms: [Nausea/Vomiting/Dizziness/Weakness/Numbness]
Current Pain Medication: [Medication/Time Given]
Response to Medication: [Effective/Partial/Ineffective]
Non-pharmacologic Measures: [Heat/Ice/Positioning/Relaxation]
Impact on Function: [Minimal/Moderate/Severe Limitation]
Client Goal: [Reduce to _/10 or Pain-free]
Plan: [Continue current/Adjust dose/Change medication/Add non-pharm measures]
Provider Notified: [Yes/No]

Fall risk assessment and precautions

Morse Fall Risk Score: [__] ([LOW <45 / MEDIUM 46-80 / HIGH >80])
Risk Factors Present:
- Age >80: [YES/NO]
- Fall History: [YES/NO]
- Secondary Diagnosis: [YES/NO]
- Ambulatory Aid Use: [NONE/CANE/WALKER/WHEELCHAIR/CRUTCHES]
- Medications: [Sedatives/Antiepileptics/Antihy pertensives/Diuretics]
- Mental Status: [Alert/Confused/Disoriented]
Gait/Balance: [Normal/Shuffling/Unsteady/Requires Assistance]
Vision: [Intact/Impaired/Blind]
Cognitive: [Alert/Confused/Disoriented]
Fall Precautions Implemented: [BED LOW/SIDE RAILS UP/CALL BELL WITHIN REACH/NON-SLIP SOCKS/CLEAR PATHWAYS]
Ambulation: [Independent/Requires Assistance]
Assistive Device: [NONE/TYPE: ___]
Bedside Commode: [YES/NO]
Frequent Toileting: [YES - SCHEDULE: ___]
Bed/Chair Alarm: [ON/OFF]
Family Educated: [YES/NO]
Risk Level: [LOW/MEDIUM/HIGH]
Interventions: [LISTED ABOVE]

Restraint documentation and monitoring

Reason for Restraint: [SAFETY/PREVENT SELF-HARM/PREVENT WANDERING/PREVENT DISLODGING LINES]
Type of Restraint: [SOFT WRIST/ANKLE/VEST/MITT/BED RAIL/OTHER: ___]
Time Applied: [__]
Provider Order: [YES/NO], Time: [__]
Alt Interventions Tried: [List: ___]
Client/Family Notification: [YES/NO]
Client Behavior Prior: [DESCRIBE]
Behavior with Restraint: [CALM/AGITATED/COMBATIVE]
Skin Integrity: [INTACT/REDNESS AT ___/BREAKDOWN]
Circulation: [Distal Pulses Intact/Sensation Intact/No Swelling]
Needs Met: [TOILETING at ___, HYDRATION offered, NUTRITION offered]
Check Frequency: [Every 15 min / Every 30 min / Every hour]
Last Check: [TIME: __, STATUS: __]
Plan for Removal: [Continue for ___ hours/Until condition resolves/Other: ___]
Comfort Measures: [Repositioning/Music/Visits]
Monitoring for Complications: [Skin breakdown/Circulation compromise/Increased agitation]

IV site assessment

IV Site Location: [LEFT/RIGHT] [ARM/HAND/FOOT/CHEST/GROIN]
Catheter Size: [24G/22G/20G/18G]
Days Since Insertion: [__]
Insertion Date/Time: [__]
Dressing: [INTACT/SOILED/NEEDS CHANGE]
Vein Assessment: [Patent/Sluggish/Occluded]
Skin Assessment:
- Erythema: [NONE/MILD/MODERATE/SEVERE] at [__ cm from site]
- Edema: [NONE/MILD/MODERATE/SEVERE]
- Warmth: [NORMAL/WARM TO TOUCH]
- Induration: [NONE/PRESENT]
- Pus/Drainage: [NONE/CLEAR/CLOUDY/PURULENT]
Palpation: [NON-TENDER/TENDER/VERY TENDER]
Infusate: [PERIPHERAL: APPROPRIATE/CENTRAL: APPROPRIATE]
Flush: [USED/NOT NEEDED], [Patent/Resistance]
Line Integrity: [INTACT/KINKED/DAMAGED]
Securement: [TAPED SECURELY/LOOSE/NEEDS REAPPLICATION]
Assessment: [PATENT/INFILTRATED/PHLEBITIS/THROMBOPHLEBITIS/INFECTION/NEED REPLACEMENT]
Actions Taken: [CONTINUE MONITORING/REAPPLY DRESSING/CHANGE IV/NOTIFY PROVIDER]

Wound assessment and documentation

Wound Location: [Anatomical location]
Wound Type: [Surgical/Pressure Injury/Traumatic/Chronic/Abrasion/Laceration/OTHER]
Days Since Wound: [__]
Size: [Length __ cm x Width __ cm x Depth __ cm]
Wound Bed:
- Color: [PINK/RED/YELLOW/BLACK/MIXED]
- Tissue Type: [EPITHELIAL/GRANULATION/SLOUGH/ESCHAR]
- Moisture: [DRY/MOIST/MACERATED/EXUDATE]
Exudate:
- Amount: [NONE/SCANT/MODERATE/COPIOUS]
- Color: [CLEAR/SEROSANGUINOUS/SANGUINOUS/PURULENT]
- Odor: [NONE/PRESENT]
Edges: [ATTACHED/DETACHED/ROLLED/UNDERMINED]
Surrounding Skin: [INTACT/MACERATED/ERYTHEMATOUS]
Sign of Infection: [NONE/ERYTHEMA/WARMTH/PURULENT DRAINAGE/FEVER/FOUL ODOR]
Pain Level: [0-10]
Dressing: [TYPE: ___], [CHANGED: ___ frequency]
Last Dressing Change: [TIME: __]
Cleansing Method: [Saline/Tap Water/OTHER]
Treatment Plan: [Continue current dressing/Change dressing type/Increase frequency/Other interventions]
Provider Notification: [Not needed/Yes - Re: ___]

Universal discharge summary

DISCHARGE SUMMARY
Admission Date: [__], Discharge Date: [__], LOS: [__] days
Admitting Diagnosis: [___]
Discharge Diagnosis: [___]
Primary Procedures/Interventions: [___]
Discharge Medications: [MEDICATION | DOSE | FREQ | INDICATION]
[___ | ___ | ___ | ___]
Allergies: [NKDA / LIST ALLERGIES]
Activity Level: [Bedrest/Limited Activity/Activity as Tolerated/No Restrictions]
Diet: [Regular/Restricted - specify: ___]
Followup Appointments: [PROVIDER: __, DATE/TIME: __, INSTRUCTIONS: __]
Referrals: [NONE/SPECIFY: ___]
Home Health: [NO/YES - Agency: ___, Services: __, Frequency: __]
Medical Equipment: [NONE/LIST: ___]
Patient Education Topics Covered: [MEDICATIONS/DIET/ACTIVITY/WOUND CARE/SYMPTOMS TO REPORT/MEDICATION SIDE EFFECTS]
Special Instructions: [___]
Person Receiving Discharge Instructions: [Patient/Caregiver: ___]
Understanding Verified: [YES/NO]
Discharge Condition: [Stable/Unstable]
Discharge Destination: [Home/Home with Services/Facility: ___]
Copy Given to Patient: [YES/NO]

Patient education with teach-back

Learner: [PATIENT / CAREGIVER — NAME/RELATIONSHIP]
Preferred Language: [__], Interpreter Used: [NO / YES — ID # AND MODALITY]
Learning Preference: [VERBAL / WRITTEN / DEMONSTRATION / VIDEO]
Barriers: [NONE / VISION / HEARING / LITERACY / COGNITION / PAIN / ANXIETY / FATIGUE]
Topic Taught: [__]
Key Points Covered: [__]
Materials Provided: [TITLE / READING LEVEL]
Teach-Back Question Asked: [SPECIFIC QUESTION]
Patient/Caregiver Response: [ACCURATE RESTATEMENT / PARTIAL — REINFORCED AND REPEATED / UNABLE]
Return Demonstration: [PERFORMED CORRECTLY / NEEDS REINFORCEMENT / NA]
Readiness to Learn: [READY / DEFERRED — REASON, WILL REATTEMPT AT __]
Follow-Up Teaching Needed: [TOPICS], Communicated to Oncoming RN: [YES]

Patient refusal of care or treatment

Treatment/Intervention Refused: [SPECIFIC]
Date/Time of Refusal: [__]
Patient's Stated Reason (own words): [QUOTE]
Decision-Making Capacity: [APPEARS INTACT — ORIENTED, ABLE TO STATE RISKS AND ALTERNATIVES / QUESTIONABLE — PROVIDER NOTIFIED]
Risks Explained: [SPECIFIC CLINICAL CONSEQUENCES DISCUSSED]
Benefits and Alternatives Offered: [__]
Patient Verbalized Understanding of Risks: [YES/NO]
Provider Notified: [NAME], Time: [__], Response: [__]
Family/Surrogate Involved: [YES — NAME / NO / PATIENT DECLINED]
Alternative Accepted: [__ / NONE]
AMA Form Signed: [YES / NO — REFUSED TO SIGN, WITNESSED BY __]
Safety Plan and Return Precautions Given: [__]
Documented in Care Plan and Handoff: [YES]

Objective event note (no reference to incident report)

Date/Time of Event: [__]
Location: [__]
Objective Description of What Occurred: [FACTS ONLY — NO SPECULATION, NO BLAME, NO OPINION]
Who Was Present: [NAMES/ROLES]
Patient Condition Immediately After: LOC [__], VS [__], injuries [NONE APPARENT / DESCRIBE], pain [0-10]
Assessments Performed: [__]
Interventions Provided: [__]
Provider Notified: [NAME], Time: [__], Orders: [__]
Family/Representative Notified: [NAME/RELATIONSHIP], Time: [__], By: [__]
Ongoing Monitoring Ordered: [__]
Patient Response to Interventions: [__]
Note: document the clinical facts here only; complete the organizational event report separately per policy and do not reference the report in the medical record.

Pressure injury risk and prevention bundle

Braden Score: [__] (sensory [__], moisture [__], activity [__], mobility [__], nutrition [__], friction/shear [__])
Risk Level: [MILD / MODERATE / HIGH / SEVERE]
Skin Inspection Completed: [HEAD TO TOE], Time: [__], Second RN Verification on Admission: [NAME]
Existing Skin Injuries: [NONE / LOCATION, STAGE, PRESENT ON ADMISSION YES-NO]
Pressure Points Assessed: sacrum, heels, occiput, elbows, trochanters, ischium, under devices
Device-Related Risk: [O2 TUBING / SpO2 PROBE / TUBES / COLLAR / SCDs], Repositioned: [YES]
Turning Schedule: q[__] hrs, Last Turn: [TIME], Position: [__]
Surfaces: [SPECIALTY MATTRESS / CHAIR CUSHION / HEEL OFFLOADING BOOTS / FLOAT HEELS]
Moisture Management: [BARRIER CREAM / INCONTINENCE PLAN / ABSORBENT PADS]
Nutrition: [DIET], intake [__]%, albumin/prealbumin [__], dietitian consult [PLACED/NOT INDICATED]
Mobility: [OOB TO CHAIR / AMBULATED __ FT / PT CONSULT]
Wound Care Consult: [PLACED / NOT INDICATED]

Admission database and initial nursing assessment

Arrival: [DATE/TIME], From: [ED / DIRECT / TRANSFER FROM __ / OR]
Mode: [AMBULATORY / WHEELCHAIR / STRETCHER], Accompanied By: [__]
Admitting Diagnosis: [__], Admitting Provider: [__]
Allergies: [AGENT — REACTION], Band Applied: [YES]
Code Status: [__], Advance Directive: [ON FILE / REQUESTED / DECLINED]
Home Medications Reconciled: [YES — SEE MED REC], Pharmacy: [__]
Pertinent History: [__], Surgeries: [__]
Baseline Functional Status: [INDEPENDENT / ASSISTIVE DEVICE / ASSIST x__], Home Support: [__]
Baseline Cognition: [__], Sensory Aids: [GLASSES / HEARING AIDS / DENTURES — LOCATION]
Screenings Completed: fall risk [__], Braden [__], nutrition [__], suicide risk [__], substance use [__], abuse-neglect [__]
Admission VS and Assessment: [SEE SHIFT ASSESSMENT]
Orientation to Unit: call light, bed controls, room layout, meal times, visiting, safety [COMPLETED]
Belongings: [INVENTORIED / SENT HOME WITH __]
Preferred Name and Communication Needs: [__], Interpreter Needs: [__]

Unit-to-unit transfer handoff

Transfer From: [UNIT] To: [UNIT], Reason: [__], Order From: [PROVIDER], Time: [__]
Patient: [NAME/MRN/AGE], Allergies: [__], Code Status: [__], Isolation: [__]
Admitting/Current Diagnosis: [__], Hospital Day: [__]
Current Status: VS [__], neuro [__], resp support [__], pain [__]
Active Concerns and Recent Changes: [__]
Lines/Drains/Tubes: [TYPE/SITE/DAY/OUTPUT]
Drips Running: [AGENT/RATE/LAST TITRATION]
Medications Due Within 2 Hours: [__]
Pending Labs/Imaging/Consults: [__]
Diet/Activity/Precautions: [__], Fall Risk: [__], Skin: [__]
Family Contact: [NAME/PHONE], Notified of Transfer: [YES/NO], Time: [__]
Belongings Transferred: [LIST]
Report Given To: [RN NAME/UNIT], Time: [__], Questions Answered: [YES]
Patient Transported By: [__], Monitor During Transport: [YES/NO], Arrived: [TIME]

Non-violent medical/surgical restraint monitoring

Clinical Justification: [INTERFERENCE WITH __ — ETT, LINES, DRAINS, SURGICAL SITE]
Alternatives Attempted and Failed: [REORIENTATION / DISTRACTION / MITTS / FAMILY PRESENCE / SITTER / TUBE CONCEALMENT / MEDICATION REVIEW]
Restraint Type: [SOFT WRIST x__ / MITTS / VEST], Applied: [DATE/TIME]
Order: [PROVIDER NAME], Time: [__], Renewed: [DATE/TIME], Frequency Per Policy: [__]
Monitoring q[__]: circulation and skin under restraint [INTACT], sensation and movement [INTACT], restraint [PROPERLY APPLIED, QUICK-RELEASE ACCESSIBLE]
Q2H Care: ROM performed, repositioned, hydration offered, toileting offered, hygiene
Patient Behavior at Each Check: [__]
Least Restrictive Alternative Reattempted: [TIME/OUTCOME]
Family Notified and Educated: [YES/NO], Time: [__]
Discontinued: [DATE/TIME], Behavior at Discontinuation: [__]
Care Plan Updated: [YES]

Oxygen therapy and respiratory support documentation

Indication: [SpO2 __% ON __ / DYSPNEA / POST-PROCEDURE / PROTOCOL]
Delivery Device: [NASAL CANNULA / SIMPLE MASK / VENTURI / NON-REBREATHER / HFNC / BIPAP / CPAP]
Settings: FiO2 [__]% or flow [__] L/min, [HFNC FLOW __ / IPAP __ / EPAP __]
Start Time: [__], Ordered By: [PROVIDER / PROTOCOL]
SpO2 Before: [__]% on [__], After: [__]% at [TIME]
Respiratory Assessment: RR [__], effort [__], breath sounds [__], accessory muscle use [__], speech [FULL SENTENCES / PHRASES / WORDS]
Mental Status: [__]
ABG/VBG: [__] at [TIME]
Skin Integrity Under Device: nares, ears, bridge of nose, mask seal area [INTACT / BREAKDOWN — INTERVENTION]
Humidification: [IN USE / NA], Oral Care: [TIME]
Weaning: [TITRATED DOWN TO __ AT TIME __ / UNABLE — SpO2 DROPPED TO __]
RT Involved: [YES/NO], Provider Notified of: [__], Time: [__]

Inpatient discharge planning and readiness

Anticipated Discharge Date: [__], Disposition: [HOME / HOME WITH HOME HEALTH / SNF / REHAB / LTAC / SHELTER / OTHER]
Discharge Barriers: [NONE / TRANSPORTATION / INSURANCE AUTH / EQUIPMENT / CAREGIVER / HOUSING / MEDICATION COST]
Case Management/Social Work Involved: [NAME], Date: [__]
Equipment Ordered: [DME ITEMS], Vendor: [__], Delivery: [DATE]
Home Services Arranged: [HOME HEALTH RN / PT / OT / INFUSION], Agency: [__], First Visit: [DATE]
Medications: prescriptions sent to [PHARMACY], prior auth needed [__], affordability discussed [YES/NO]
Follow-Up Appointments: [PROVIDER/DATE/TIME], Made By: [__], Patient Has Written Copy: [YES]
Caregiver Training Completed: [TOPICS], Return Demonstration: [__]
Transportation Plan: [__]
Functional Status vs Baseline: [AT BASELINE / DECLINED — SUPPORTS ARRANGED]
Discharge Readiness Criteria Met: [VS STABLE / PAIN CONTROLLED / TOLERATING DIET / VOIDING / AMBULATING / EDUCATION COMPLETE]
Outstanding Items: [__]

Critical lab or imaging value notification

Value Type: [LAB / IMAGING / DIAGNOSTIC]
Result: [TEST NAME AND VALUE], Reference Range: [__]
Received: [DATE/TIME], From: [LAB TECH / RADIOLOGIST NAME]
Read-Back Verification Completed: [YES], Time: [__]
Patient Condition at Time of Result: [ASYMPTOMATIC / SYMPTOMS — DESCRIBE], VS: [__]
Provider Notified: [NAME/ROLE], Method: [PHONE / SECURE MESSAGE / IN PERSON], Time: [__]
If No Response: escalation to [NAME], Time: [__], Chain of Command Followed Per Policy
Orders Received: [__], Read Back and Verified: [YES], Time: [__]
Interventions Carried Out: [__], Time: [__]
Repeat/Confirmatory Test: [ORDERED — TIME / NOT ORDERED]
Patient Response and Reassessment: [__]
Handoff Communicated To: [ONCOMING RN], Time: [__]

End-of-shift summary and handoff

Shift: [DATE/HOURS], Nurse: [NAME]
Patient Summary: [NAME/AGE/DIAGNOSIS/HOSPITAL DAY]
Overall Trend This Shift: [IMPROVED / STABLE / DECLINED]
Significant Events: [__]
VS Trend: [RANGES]
Pain Management: [REGIMEN AND EFFECTIVENESS]
Intake/Output: [__] in / [__] out, net [__]
Procedures/Tests Completed: [__], Results: [__]
Medication Changes: [__], Doses Held: [AGENT — REASON]
Provider Communication: [WHO/WHEN/WHAT]
Family Communication: [WHO/WHEN/WHAT]
Pending for Next Shift: [LABS / IMAGING / CONSULTS / ORDERS / EDUCATION]
Anticipated Needs and Watch-Fors: [SPECIFIC]
Report Given To: [RN NAME], Time: [__], Bedside Handoff: [YES/NO]