Organizational Tool

Published

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.

oranizational tool

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:

drug

dose

route

frequency

remarks

Hi 2BSure,

Send me a private message with your email address. I will be glad to send it to you. Thanks.

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