1. BRAIN SHEET – NEW SHIFT REPORT
Room:____________ DATE:____________
Patient______________________Age___Sex____ Admitted: _____HD:________LOS:_______
Diagnosis:__________________________Procedure___________________________________
Comorbid ConditionsHx:_____________ Code Status:______Allergies____________________
______________________________________________________________________________
SIGNIFICANT HOSPITAL HISTORY BODY SYSTEMS
Neuro: Neuro: PLAN: VARIANCE
Orientation:
Psych/Soc Pupils:
Extremity Strength Temp:
Activity Weight:
Fall Precaution: Restraints
CV: Cardiovascular: PLAN: VARIANCE
Rhythm: HR:
BP:
“A” Line
Swan Ganz: PA PAWP
CVP: CO
Pacer Wires:
K+: CPK: CBC: Hct: PT
Mg+: MB’s: Trop: HGB PTT
Ca:
Edema (small= +1 moderate=+2 Pitting= +3)
Pulses (R) (L) (absent=0 weak=1 strong=2)
PICC/Central line/ IJ:
Hep Lock:
DRIPS: cc/hr
PUL: Extub: RR: O2 Respiratory PLAN: VARIANCE
BS: Mask:
Coughing Sputum Triflow
Chest Tubes: Bipap:
ABG: Mode: Cuff Pressure
FiO2
TV rate
GI Abd Contour GI: PLAN: VARIANCE
BS Flatus:
NG pH:
Diet: BM
Feeding Appetite:
Chemstrip:
GU Foley: Cath Care: SG GU: PLAN: VARIANCE
PD I&O’s
Urine Output: Hemo
Skin/dressing/incisions: Specimens:
Test, Labs
Braden Scale: Procedures, hx, preps
Other: Other:
Discharge Plan: Teaching/Learning:
Consults:
Variance to Discharge Plan: Barrier
Resolution: Special Needs:
Consults:
Ca PTT CPK CKMB%
Mg PT CKMB TROP