hi,
in the course of my job as a clinical instructor, i have encountered students having issues with organizing their patient information (which is i could understand cause they are still students and need guidance). in our case, students have to go to the hospital the day before to pick up patient information. some of them will write in a small notebook and some will write in loose papers (that easily get lost). there are some others, for some reason or another, will miss important information that they need to fill up their concept maps (e.g., vital signs or lab works). so, i came up with the organizational tool (i have copied and pasted below, can't attach the file probably because it is more than the required) below. i gave the students copy, they can fill it up with the patient information and hopefully, they will not forget some of the most important information they need.
on their last day, i asked them to turn in a revised version to tailor to their individual needs.
if anybody is interested, please feel free to copy and paste, edit or revise according to your need.
thanks.
patient's initials: _____________________ age: __________________ rm. no: ______________
marital status: ______________________ sex: __________________
date of birth: _______________________
allergy: medications: _______________________________ food: _________________________________
contrast media: ___________________________________ environmental: __________________________
primary md: __________________________________________________________________________________
consults: _____________________________________________________________________________________
date of admission: _____________________________________________________________________________
chief complaint: _______________________________________________________________________________
diagnosis: ____________________________________________________________________________________
health history: ________________________________________________________________________________
_____________________________________________________________________________________________
date/surgical procedure: ________________________________________________________________________
date/procedure: _______________________________________________________________________________
results: ______________________________________________________________________________________
admission vital signs: bp: ________________ hr: ______________ rr: ___________ temp: ___________
o2 sats: ____________
date of visit vital signs: bp: ______________ hr: _____________ rr: _____________ temp: ___________
o2 sats: __________
o2: _______________________________________ respiratory tx: ______________________________
ventilator: tv: __________ fio2: ______________ rate: ____________ ac: ___________
imv: ________ ps: ________________ peep: ____________
iv: ________________________________________ diet: _______________________________________
iv site: _____________________________________ feeding tube: ________________________________
date of insertion: ____________________________ formula: ____________________________________
foley: yes no date of insertion: __________ date/ekg: ___________________________________
date/chest x-ray: ____________________________
abg: ph: __________ pco2: __________ po2: __________ hco3: ____________ o2 sat: ____________
wound (if any): _____________________________________________________________________________________________________________
lab:
date: _________
on admission:
date: _________
day pick-up info:
lab:
date: ________
on admission:
date: ________
day pick-up info:
wbc (5-10)
glucose (70-110)
rbc (4-5)
bun (5-26)
hgb (12-16 female
(14-18 male)
creatinine (.5-1.5)
hct (37-47 female)
(42-52 male)
calcium (8.5-10)
plt ct. (150-400)
potassium (3.5-5.0)
magnesium (1.5-2.0)
ua
sodium (135-145)
fingersticks:
date: _________
on admission:
date: _________
day pick-up info:
fingersticks:
bedtime
date: _________
on admission:
date: _________
day pick-up info:
blood glucose
(chf) lab:
date: _________
on admission:
date: _________
day pick-up info:
(cp/cad)lab:
date: _________
on admission:
date: _________
day pick-up info:
bnp
100-300 pg/dl = hf present
300+ = mild chf
600+ = moderate hf
900+ = severe hf
troponin 1 (
(onset: 4-6 hrs, peak: 12-24 hrs, return to normal: 4-7 days)
echocardiogram
myoglobin
male: 10 - 95 ng/ml
female: 10 - 65 ng/ml
(onset: 1-3 hrs, peak: 6-10 hrs, return to normal: 12-24 hrs)
ef (60-70%)
ck (8-150 iu/l)
ck mb (0-3.9%)
lab:
pts. on coumadin
date: _________
on admission:
date: _________
day pick-up info:
lab:
pts. on heparin
date: _________
on admission:
date: _________
day pick-up info:
pt (10 - 14 seconds)
ptt (32 - 45 seconds)
current medications:
Ace1Rnelp
44 Posts
Hi 2BSure,
Send me a private message with your email address. I will be glad to send it to you. Thanks.