Student Name___________________

Clinical Organization Sheet N126AM Report you need this information before caring for your patient

Student Name:

Patient Initials: Age: Rm: Allergies:

Medical Diagnosis:

Additional Information (catheter, dressing, present, IV, etc):

Activity: Code Status:

Diet:

Assistive Devices (wheelchair, walker, braces, etc):

Last Set Vital Sign Results & Frequency:

T

R

O2 saturation

P

BP

Oxygen Treatment:

Medications times:*Use medication organization sheet for full information

Pain Status/Management (include last time medication received):

I &O, Mental Status/Level of Consciousness:

Plan of care for day:

Your AssessmentVital Signs & Pain (note time):

Sensory System:

Labs:

Blood Sugars (time, results, coverage):

Respiratory/Oxygen:

Cardiovascular:

Gastrointestinal:

Genitourinary:

Skin, Hair, Nails:

Neurological/Psychological:

Musculoskeletal:

Hematological/Endocrine:

Report Off Communication to Your Nurse:Vital Signs (time and results)

Key Assessment Info (problem focused assessment)

Patient needs/concerns

Pain

Medication Issues

Care provided

I & O

Blood Sugars (time/results/coverage)*Remember to follow a logical, consistent order; give exact information including times; ask if there are any further questions.