Sample Charting for Nurses (for Admission of Patient to Ward)

- In from Emergency Room via stretcher, unconscious and incoherent accompanied by
relative.
- Placed on bed on moderate high bed rest position.
- Admitted a 67 y/o male, married, with the chief complaint of loss of consciousness> prior to admission.
- with ongoing
IVF's of the ff:
- Main Line: Plain NSS 1L @ 900cc level regulated @ 25gtts/min
- Side Drip 1 : D5W 250cc + 1 ampule Dopamine @ 200cc level
- Side Drip 2 : D5W 250cc + 1 ampule Dobutamine @ 200 cc level regulated @
40gtts/min
- consent for admission signed by the relatives
- still with:
- endotracheal tube connected to ambu-bag to oxygen tanks @ 10LPM
- nasogastric tube closed and intact for feeding purpose
- foley catheter connected to urine bag draining into yellowish output potent and
intact
- still for the following labs:
- FBS, lipid profile, SGOPT, SGPT
- cranial CT scan once with funds, relative informed
- urinalysis
- manual ambubagging continuously done by the watcher
- suctioning done
- advised watcher to secure oral and IV meds
- closely watched and attended.

Sign.