® Report Card Report Card e One and Only Nurse’s Report Card Copyright 2008 GogaJET, Inc. A Green Company C
Nov 12, 2014
®R
epor
tC
ard
Rep
ort
Car
d
�e
One
and
Onl
yN
urse
’s R
epor
t Car
d
Cop
yright
2008
GogaJ
ET, Inc.
A Gree
n Com
pany
Copyright 2008 GogaJET, Inc.
®R
epor
tC
ard
Rep
ort
Car
d
�e
One
and
Onl
yN
urse
’s R
epor
t Car
d
Cop
yright
2008
GogaJ
ET, Inc.
A Gree
n Com
pany PATIENT
INFORMATIONDISPOSAL
DISCLAIMERIn accordance with current HIPAA laws, please dispose of all patient
information appropriately. HIPAA protects all “individually identi�able health information” which includes all information pertaining to the
patient’s diagnosis, treatment, as well as any patient identi�ers. Be sure to utilize your facility’s approved patient data disposal systems.
Copyright 2008 GogaJET, Inc.
Join UsRN BLOG
www.rnreportcard.com/blog
FACEBOOKSearch “RNREPORT CARD”
TWI�ERwww.twi�er.com/rnreportcard
LINKEDINwww.linkedin.com/in/rnreportcard
ReportCard®ReportCard
Copyright 2008 GogaJET, Inc.
Join UsRN BLOG
www.rnreportcard.com/blog
FACEBOOKSearch “RNREPORT CARD”
TWI�ERwww.twi�er.com/rnreportcard
LINKEDINwww.linkedin.com/in/rnreportcard
ReportCard®ReportCard REORDER
INFORMATIONONLINE
www.rnreportcard.com
PHONE1-888-720-4RNS (4767)
ReportCard®ReportCard
Copyright 2008 GogaJET, Inc.
GlucoseK
BUN
CreatinineCO 2
CINa
INR MagP�PT
WBCHCT
Hbg
Plt
Med Time(s)
_______________________________
Admit:__________________________
Age:___________ Sex:_____________
MD/Service:_____________________________ Dx:______________ Admit Reason:______________________________
Rhythm/Tele#:_______________________________________ IV/Date:________________________________________ Allergies:___________________________________________________________________________________________
_________________ _________________ _________________ _________________
Vitals ______ BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
______ BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
______ BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
Daily Weight:________________________Accucheck:_____________
Fall Precautions Foley
Drips:_______________________
Drips:_______________________
Drips:_______________________
Diet:__________________
O2 Sat:________ Vent:______________________________________________________________________
Isolation: ( contact - droplets - respiratory )
Vaccines:____________________________________________________
Notes:_________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Name / Room / Bed: HX:____________________________________________________________
_______________________________________________________________
_______________________________________________________________
Activity:__________________________
Time
Time
Time
8:00 10:00 14:00 16:00
Alexandra J. Jefferson 2046 2
Rivero / GI - 305-321-2525
54 Female
07/09/ 10
NSR / 2951
Colon CA Chemo
AS Tolerated
PIV - 20 Gauge - R. hand NS @ 100 ml / hr
NKA
Regular
Crohns Disease, DM, BKA Left Leg
08:10 123 / 75 65 20 98.5 0
67 20 98.2 5
80 20 96.5 2
153 / 76
125 / 75
12:00
16:07
✓
✓
AC / HS BKA, Walker
H1N1, Influenza
- CT Scan Complete- Consent for PRBC
- PRBC
- MD Called @ 1400 for temp of 101.0
1399 1
109 24
3.6 39
1 1.2
10.6 23633.0
1.1
EXAMPLECopyright 2008 GogaJET, Inc.
PROCEDURES ASSESSMENT
AA0X3 Confused Disoriented PERRLAParalysis Pain Ambulation GaitBC ______________ _
CT Scan
CXray
Echo
EEG
EKG
MRI
UA
U C/S
U/S
X-Ray
Done Neuro:
Wheezes Crackles Rhonchi RalesStridor Trach 02 ISChest Tube Cough Non/Productive
Respiratory:
Pulses HR S3 S4EdemaRhythm & Character
Vascular Access Devices Capillary Re�ll
Cardio:
Pending
Apical
So� Distended BMNG Tube N/VColostomy Incontinent
GI:
FlatusTube Feeding
+ BSIleostomy
Voiding TURP
Character
Bladder Distened
CBIIncontinent Nephrostomy TubeMiami Pouch
Foley
GU:
Edema drsg IncisionTurgor Clammy Dry IntactFrictionRashes Stage I Stage II Stage III
TEDS SCD Lesions
Intergumentary:Temp
Neuro ENT OptometryCardiac Pulmonary GI ColorectalGUDerm
GYO Nephrology IDSurgery Anesthesia Plastics
Oncology Speech Ortho SpinePainSocial Work
Wound Care RadOnc Psych
Consults:Endocrine
Notes:___________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______ ______________ _
✓ ✓
✓
✓ ✓
X2
infiltrates
✓
✓
✓✓
✓
✓
✓ ✓
✓ ✓
02 - NC - 2 L
+ 2 Edema BLE
EXAMPLE
07/09/ 10
07/09/ 10
GlucoseK
BUN
CreatinineCO 2
CINa
INR MagP�PT
WBCHCT
Hbg
Plt
Med Time(s)
_______________________________
Admit:__________________________
Age:___________ Sex:_____________
MD/Service:_____________________________ Dx:______________ Admit Reason:______________________________
Rhythm/Tele#:_______________________________________ IV/Date:________________________________________ Allergies:___________________________________________________________________________________________
_________________ _________________ _________________ _________________
Vitals ______ BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
______ BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
______ BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
Daily Weight:________________________Accucheck:_____________
Fall Precautions Foley
Drips:_______________________
Drips:_______________________
Drips:_______________________
Diet:__________________
O2 Sat:________ Vent:______________________________________________________________________
Isolation: ( contact - droplets - respiratory )
Vaccines:____________________________________________________
Notes:_________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Name / Room / Bed: HX:____________________________________________________________
_______________________________________________________________
_______________________________________________________________
Activity:__________________________
Time
Time
Time
8:00 10:00 14:00 16:00
Alexandra J. Jefferson 2046 2
Rivero / GI - 305-321-2525
54 Female
07/09/ 10
NSR / 2951
Colon CA Chemo
AS Tolerated
PIV - 20 Gauge - R. hand NS @ 100 ml / hr
NKA
Regular
Crohns Disease, DM, BKA Left Leg
08:10 123 / 75 65 20 98.5 0
67 20 98.2 5
80 20 96.5 2
153 / 76
125 / 75
12:00
16:07
✓
✓
AC / HS BKA, Walker
H1N1, Influenza
- CT Scan Complete- Consent for PRBC
- PRBC
- MD Called @ 1400 for temp of 101.0
1399 1
109 24
3.6 39
1 1.2
10.6 23633.0
1.1
EXAMPLE
PROCEDURES ASSESSMENT
AA0X3 Confused Disoriented PERRLAParalysis Pain Ambulation GaitBC ______________ _
CT Scan
CXray
Echo
EEG
EKG
MRI
UA
U C/S
U/S
X-Ray
Done Neuro:
Wheezes Crackles Rhonchi RalesStridor Trach 02 ISChest Tube Cough Non/Productive
Respiratory:
Pulses HR S3 S4EdemaRhythm & Character
Vascular Access Devices Capillary Re�ll
Cardio:
Pending
Apical
So� Distended BMNG Tube N/VColostomy Incontinent
GI:
FlatusTube Feeding
+ BSIleostomy
Voiding TURP
Character
Bladder Distened
CBIIncontinent Nephrostomy TubeMiami Pouch
Foley
GU:
Edema drsg IncisionTurgor Clammy Dry IntactFrictionRashes Stage I Stage II Stage III
TEDS SCD Lesions
Intergumentary:Temp
Neuro ENT OptometryCardiac Pulmonary GI ColorectalGUDerm
GYO Nephrology IDSurgery Anesthesia Plastics
Oncology Speech Ortho SpinePainSocial Work
Wound Care RadOnc Psych
Consults:Endocrine
Notes:___________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______ ______________ _
✓ ✓
✓
✓ ✓
X2
infiltrates
✓
✓
✓✓
✓
✓
✓ ✓
✓ ✓
02 - NC - 2 L
+ 2 Edema BLE
EXAMPLE
07/09/ 10
07/09/ 10
Copyright 2008 GogaJET, Inc.
Copyright 2008 GogaJET, Inc.
GlucoseK
BUN
CreatinineCO 2
CINa
INR MagP�PT
WBCHCT
Hbg
Plt
Med Time(s)
_______________________________
Admit:__________________________
Age:___________ Sex:_____________
MD/Service:_____________________________ Dx:______________ Admit Reason:______________________________
Rhythm/Tele#:_______________________________________ IV/Date:________________________________________ Allergies:___________________________________________________________________________________________
_________________ _________________ _________________ _________________
Vitals ______ BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
______ BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
______ BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
Daily Weight:________________________Accucheck:_____________
Fall Precautions Foley
Drips:_______________________
Drips:_______________________
Drips:_______________________
Diet:__________________
O2 Sat:________ Vent:______________________________________________________________________
Isolation: ( contact - droplets - respiratory )
Vaccines:____________________________________________________
Notes:_________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Name / Room / Bed: HX:____________________________________________________________
_______________________________________________________________
_______________________________________________________________
Activity:__________________________
Time
Time
Time
PROCEDURES ASSESSMENT
AA0X3 Confused Disoriented PERRLAParalysis Pain Ambulation GaitBC ______________ _
CT Scan
CXray
Echo
EEG
EKG
MRI
UA
U C/S
U/S
X-Ray
Done Neuro:
Wheezes Crackles Rhonchi RalesStridor Trach 02 ISChest Tube Cough Non/Productive
Respiratory:
Pulses HR S3 S4EdemaRhythm & Character
Vascular Access Devices Capillary Re�ll
Cardio:
Pending
Apical
So� Distended BMNG Tube N/VColostomy Incontinent
GI:
FlatusTube Feeding
+ BSIleostomy
Voiding TURP
Character
Bladder Distened
CBIIncontinent Nephrostomy TubeMiami Pouch
Foley
GU:
Edema drsg IncisionTurgor Clammy Dry IntactFrictionRashes Stage I Stage II Stage III
TEDS SCD Lesions
Intergumentary:Temp
Neuro ENT OptometryCardiac Pulmonary GI ColorectalGUDerm
GYO Nephrology IDSurgery Anesthesia Plastics
Oncology Speech Ortho SpinePainSocial Work
Wound Care RadOnc Psych
Consults:Endocrine
Notes:___________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______ ______________ _
GlucoseK
BUN
CreatinineCO 2
CINa
INR MagP�PT
WBCHCT
Hbg
Plt
Med Time(s)
_______________________________
Admit:__________________________
Age:___________ Sex:_____________
MD/Service:_____________________________ Dx:______________ Admit Reason:______________________________
Rhythm/Tele#:_______________________________________ IV/Date:________________________________________ Allergies:___________________________________________________________________________________________
_________________ _________________ _________________ _________________
Vitals ______ BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
______ BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
______ BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
Daily Weight:________________________Accucheck:_____________
Fall Precautions Foley
Drips:_______________________
Drips:_______________________
Drips:_______________________
Diet:__________________
O2 Sat:________ Vent:______________________________________________________________________
Isolation: ( contact - droplets - respiratory )
Vaccines:____________________________________________________
Notes:_________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Name / Room / Bed: HX:____________________________________________________________
_______________________________________________________________
_______________________________________________________________
Activity:__________________________
Time
Time
Time
PROCEDURES ASSESSMENT
AA0X3 Confused Disoriented PERRLAParalysis Pain Ambulation GaitBC ______________ _
CT Scan
CXray
Echo
EEG
EKG
MRI
UA
U C/S
U/S
X-Ray
Done Neuro:
Wheezes Crackles Rhonchi RalesStridor Trach 02 ISChest Tube Cough Non/Productive
Respiratory:
Pulses HR S3 S4EdemaRhythm & Character
Vascular Access Devices Capillary Re�ll
Cardio:
Pending
Apical
So� Distended BMNG Tube N/VColostomy Incontinent
GI:
FlatusTube Feeding
+ BSIleostomy
Voiding TURP
Character
Bladder Distened
CBIIncontinent Nephrostomy TubeMiami Pouch
Foley
GU:
Edema drsg IncisionTurgor Clammy Dry IntactFrictionRashes Stage I Stage II Stage III
TEDS SCD Lesions
Intergumentary:Temp
Neuro ENT OptometryCardiac Pulmonary GI ColorectalGUDerm
GYO Nephrology IDSurgery Anesthesia Plastics
Oncology Speech Ortho SpinePainSocial Work
Wound Care RadOnc Psych
Consults:Endocrine
Notes:___________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______________ _
______ ______________ _
Copyright 2008 GogaJET, Inc.
LAB VALUES
Sodium (Na+)
Potassium (K+)
Chloride (CI _)
Carbon dioxide (C02)
Anion Gap
Glucose
BUN
Creatinine
Glomer Filt Rat
TBIL
AST
Total Protein
Albumin
Calcium (Ca+)
ALT (SGPT)
135 - 145 mmol / L
3.5 - 5.2 mmol / L
95 - 110 mmol / L
19 - 34 mmol / L
6 - 22 mg / dL
70 - 110 mg / dL
6 - 22 mg / dL
0.6 - 1.3 mg / dL
>60 ml / min
0.1 - 1.1 mg / d
10 - 40 U / L
5.5 - 8.7 g / dL
3.2 - 5.0 g / dL
8.7 - 10.5 mg / dL
7 - 55 U / L
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
Platelets
Neutrophil %
Lymphocyte %
Monocyte %
Eosinophil %
Basophil %
3.5 - 9.6 mm3
3.8 - 5.2 M / uL
11.8 - 15.4 gm / dL
34.7 - 45.2 %
81.0 - 97.0 f l
26.0 - 34.0 pg
28.0 - 37.0 gm / dL
11.5 - 15.0 %
147 - 354 mm3
36 - 66 %
23.0 - 43.0 %
0.0 - 10.0 %
0.0 - 5.0 %
0.0 - 1.0 %
Copyright 2008 GogaJET, Inc.
LAB VALUES
Sodium (Na+)
Potassium (K+)
Chloride (CI _)
Carbon dioxide (C02)
Anion Gap
Glucose
BUN
Creatinine
Glomer Filt Rat
TBIL
AST
Total Protein
Albumin
Calcium (Ca+)
ALT (SGPT)
135 - 145 mmol / L
3.5 - 5.2 mmol / L
95 - 110 mmol / L
19 - 34 mmol / L
6 - 22 mg / dL
70 - 110 mg / dL
6 - 22 mg / dL
0.6 - 1.3 mg / dL
>60 ml / min
0.1 - 1.1 mg / d
10 - 40 U / L
5.5 - 8.7 g / dL
3.2 - 5.0 g / dL
8.7 - 10.5 mg / dL
7 - 55 U / L
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
Platelets
Neutrophil %
Lymphocyte %
Monocyte %
Eosinophil %
Basophil %
3.5 - 9.6 mm3
3.8 - 5.2 M / uL
11.8 - 15.4 gm / dL
34.7 - 45.2 %
81.0 - 97.0 f l
26.0 - 34.0 pg
28.0 - 37.0 gm / dL
11.5 - 15.0 %
147 - 354 mm3
36 - 66 %
23.0 - 43.0 %
0.0 - 10.0 %
0.0 - 5.0 %
0.0 - 1.0 %
Copyright 2008 GogaJET, Inc.
REORDERINFORMATION
ONLINEwww.rnreportcard.com
PHONE1-888-720-4RNS (4767)
ReportCard®ReportCard
Copyright 2008 GogaJET, Inc.
FUN MEDICAL FACTSReport
Card®ReportCard
Find More Fun Facts and RN Blogs @ http://www.rnreportcard.com
Did you know it is impossible for you tosneeze with your eyes open?
The
One
and
Only
Nurs
e’s
Repo
rt C
ard!
Contact us
to r
eord
er!
Onl
ine:
www
.rnre
portc
ard.
com
Phon
e: 1
-888
-720
-476
7
Copy
righ
t 20
08 G
ogaJ
ET, Inc
.
The
One
and
Only
Nurs
e’s
Repo
rt C
ard!
Contact us
to r
eord
er!
Onl
ine:
www
.rnre
portc
ard.
com
Phon
e: 1
-888
-720
-476
7
Copy
righ
t 20
08 G
ogaJ
ET, Inc
.