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Kardex form for patient assignments

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Dawn Zoerner

This clinical worksheet provides information about a patient including their initials, room number, age, gender, weight, height, occupation, and ethnic group. It notes the patient's admit date and admit diagnosis, as well as the surgical procedure they underwent and the date of surgery. It outlines the patient's pertinent past medical history, current medical orders, baseline vital signs, IV fluids and rate, respiratory treatments, upcoming lab orders, vital sign frequency, neuro checks, activities including diet, intake and output, dressings, diagnostics, and other post-op care instructions.

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ADN CLINICAL WORKSHEET Date______Student__________________________ CLIENT INITIALS______RM#______AGE_____GENDER_____WT______HT______OCCUPATION_______________________ETHNICGROUP_______________________ ADMIT DATE_______ADMIT DX_______________________________________ SURGICAL PROCEDURE: _______________________________________________________ SURGERY DATE_________POST-OP DATE OF CARE______________ALLERGIES____________________________________________________CODE STATUS_________ Research of Medical Dx. Research of Surgical Procedure and/or Procedures/Diagnostics Pertinent Past Medical History Medical Orders Relevant to the Plan of Care Admission V/S (baseline): Previous Shift V/S (baseline): IV Fluid/Rate (ml/hr): Oxygen: Resp. Tx. (type & frequency): Current Lab Orders (for your day(s) of care): V/S frequency: Neuro checks (frequency): Heplock or Saline lock flush Activities Bedrest HOB_____ Turn_____ Chair____amb._____ ROM____dangle_____ Physical Therapy Treatment: Traction lbs.:____ Diet Order: Encourage/Restrict fluids I & O frequency: Foley Straight cath. Condom cath. Dressing Changes: Suction &/or Drains Gastric: Wound: Other: Current Diagnostic Tests (for your day(s) of care: Glucoscan/Accucheck frequency: PAS stockings or TED hose Bath type: _______________ Any Other Treatment Specific to Your Pt. Psycho-social and Spiritual Issues Tubefeeding: Resid. 4: PEG or NG Post-Op Care Cough/deep breath frequency: Incentive Spirometer frequency:

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Kardex form for patient assignments

  • 1. ADN CLINICAL WORKSHEET Date______Student__________________________ CLIENT INITIALS______RM#______AGE_____GENDER_____WT______HT______OCCUPATION_______________________ETHNICGROUP_______________________ ADMIT DATE_______ADMIT DX_______________________________________ SURGICAL PROCEDURE: _______________________________________________________ SURGERY DATE_________POST-OP DATE OF CARE______________ALLERGIES____________________________________________________CODE STATUS_________ Research of Medical Dx. Research of Surgical Procedure and/or Procedures/Diagnostics Pertinent Past Medical History Medical Orders Relevant to the Plan of Care Admission V/S (baseline): Previous Shift V/S (baseline): IV Fluid/Rate (ml/hr): Oxygen: Resp. Tx. (type & frequency): Current Lab Orders (for your day(s) of care): V/S frequency: Neuro checks (frequency): Heplock or Saline lock flush Activities Bedrest HOB_____ Turn_____ Chair____amb._____ ROM____dangle_____ Physical Therapy Treatment: Traction lbs.:____ Diet Order: Encourage/Restrict fluids I & O frequency: Foley Straight cath. Condom cath. Dressing Changes: Suction &/or Drains Gastric: Wound: Other: Current Diagnostic Tests (for your day(s) of care: Glucoscan/Accucheck frequency: PAS stockings or TED hose Bath type: _______________ Any Other Treatment Specific to Your Pt. Psycho-social and Spiritual Issues Tubefeeding: Resid. 4: PEG or NG Post-Op Care Cough/deep breath frequency: Incentive Spirometer frequency: