Forms

Question 1

Forms

Answer 1

-Nursing admission data forms
-Discharge summary

Question 2

Flow sheets and graphic sheets

Answer 2

Vertical or horizontal columns for recording dates and times and related assessment and intervention information:​

Vital Signs​

Intake and Output​

Assessment​ check list

Question 3

Medication Administration Records

Answer 3

Scheduled meds
unscheduled meds
drug allergies
single order medications

Question 4

Kardex

Answer 4

A summary worksheet reference of basic information that traditionally is not part of the record. Usually contains:​

Patient’s data (name, age, marital status, religious preference, physician, family contact).​

Medical diagnoses: listed by priority.​

Allergies.​

Medical orders (diet, IV therapy, etc.).​

Activities permitted.​

Question 5

Nurse’s Progress Notes/Narrative

Answer 5

Patient’s condition, problems, and complaints.​

Interventions.​

Patient’s response to interventions.​

Achievement of outcomes.​

Additional assessment​

***Report given, and report received​

-Time​

-Nurse’s name​

-Important information​

-Do immediately