Nurse Brain – 2-Up Fillable

Rm: Name: Age: Sex:

Admit: MD: Allergies:

Diet: Activity:

Code: Full DNR DNI Safety: Fall Seiz Suic Asp

Iso: Contact Droplet Airborne BG: Q1 Q4 Q6 AC/HS

Dx/CC:

PMHx:

SYSTEMS ASSESSMENT

Neuro:

CV:

Resp:

GI:

GU:

Skin:

MSK:

Endo:

Psych:

Pain:

ID/Iso:

Other:

VITAL SIGNS (Q4 / Q8)

Time	T	HR	BP	RR	O₂	Pain	BG

LABORATORY VALUES

WBC

Hgb

Hct

Plt

PT

PTT

INR

Fib

Na

K

Cl

CO₂

Ca

Mg

Phos

Alb

BUN

Cr

GFR

Glu

Trop

BNP

Lac

Pro

INTAKE

OUTPUT

LINES / ACCESS / DRAINS

NOTES / PLAN / TO DO

Rm: Name: Age: Sex:

Admit: MD: Allergies:

Diet: Activity:

Code: Full DNR DNI Safety: Fall Seiz Suic Asp

Iso: Contact Droplet Airborne BG: Q1 Q4 Q6 AC/HS

Dx/CC:

PMHx:

SYSTEMS ASSESSMENT

Neuro:

CV:

Resp:

GI:

GU:

Skin:

MSK:

Endo:

Psych:

Pain:

ID/Iso:

Other:

VITAL SIGNS (Q4 / Q8)

Time	T	HR	BP	RR	O₂	Pain	BG

LABORATORY VALUES

WBC

Hgb

Hct

Plt

PT

PTT

INR

Fib

Na

K

Cl

CO₂

Ca

Mg

Phos

Alb

BUN

Cr

GFR

Glu

Trop

BNP

Lac

Pro

INTAKE

OUTPUT

LINES / ACCESS / DRAINS

NOTES / PLAN / TO DO