The patient’s name and age
The patient’s code status
Any isolation precautions
The patient’s admitting diagnosis, including the most relevant parts of their history and other diagnoses
Important or abnormal findings for all body systems:
Respiratory: Is the patient on oxygen? If so, how many liters per minute are they getting?
Cardiovascular: Is the patient on telemetry? Are they on a cardiac drip or heparin drip?
Neuro: What is the patient’s level of consciousness?
Musculoskeletal: Is the patient mobile or bed-bound? Can they get up independently or do they require assistance?
Gastrointestinal & Urinary: Does the patient have any diet restrictions? When was their last bowel movement? Are they incontinent and do they have a catheter in place? What kind of catheter?
Skin: Does the patient have any wounds or pressure injuries?
Is the patient diabetic and are blood sugar checks required?
What kind of IV access does the patient have? Are they getting continuous fluids? If so, which fluid?
Is the patient on any antibiotics? Are they taking pain medication(s)? If so, when was their last dose?
Does the patient require certain tests that day? Do they need wound care? Will the patient be discharged during that nurse’s shift?