This Nurse Report Sheet can be used by nursing staff during ward or room visits. Start by entering the patient's general information. Next, record diagnosis and the medical history. It is also important to take note any allergy and special conditions. The template then prompts the user to record vital signs of the patient such as blood pressure, heart rate, temperature, and blood sugar. Med passes should also be recorded to ensure that medicines are dispensed accordingly. Document the patient's food intake during breakfast, lunch, or supper. Lastly, write down any future procedure needed to inform the next nurses-on duty. Complete the report by providing a digital signature. Use SafetyCulture to perform digital patient checks with the use of your handheld device. You may also customize this template based on your needs.
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Nursing SOAP Note
Nurses can use this SOAP note template to collect patient's information for admission purposes. Use this checklist to take note of the patient's concerns and needs. Gather information needed for treatment by recording the results of physical observations and laboratory tests.
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Nursing Audit Checklist
Nursing audit is the process of determining the quality of nursing care by reviewing clinical records made by healthcare professionals. It helps ensure consistent quality patient care and uncover areas for improvement. Use this nursing audit checklist to confirm compliance with proper nursing documentation and check patient care provided to patients (currently in admission or discharged).
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Non-Conformance Report Form
Use this general non-conformance report form template to document any plan deviation or any non-conformances in quality observed in the workplace. This form should be made available to all staff or members. Start by completing details of non-conformance report: type, priority, source, process, detailed description of the case and photos (optional). The staff who raised the issue should affix a digital signature to validate the report. The template should then be endorsed to the manager or any authorized personnel. After receiving the template, the manager should enter corrective or preventive actions to be implemented and assign it to responsible teams or professionals to take necessary actions. After completion of the task, send this back to the manager for verification and closure. Provide an overall rating and provide a digital signature to complete the report.
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General Patient Fall Risk Assessment Template
This fall risk assessment template is used to evaluate a patient's probability of falling. It includes fields to record a patient's fall history, current medication, and medical test results (vision, peripheral sensation, and mobility). Record the patient's fall risk rating depending on the number of accumulated risk factors. If a patient gets 1-2 risk factors patient has a Low risk probability of falling, a Medium risk for 3-5 risk factors and High risk for 6 risk factors and above.
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