The RNReport Card nursing notes for medical report

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RNReport Card is easy, portable, and keeps all of your patient information in a handy place. The Shift Report booklet fits in the pockets of your scrubs and is lightweight. There is room to keep all your important patient information like name, room, diagnosis, procedures, assessment, consults, medication times, drips, IV fluids, and much much more


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The RNReport Card is a portable Nurse's report sheet booklet that is 5 x 7 inches, fits comfortable in your pocket, and is lightweight.

Environmentally Friendly materials, process and procedures.

Soy Based Inks printed on Durable 80lbs UV coated Recycled Paper.40 Individual pages. 1 Page is designated for 1 Patient

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT / PATIENT INFORMATION DISPOSAL DISCLAIMER

In accordance with current HIPAA laws, please
dispose of all patient information appropriately. HIPAA protects all “individually identifiable health
information” which includes all information pertaining to the patient’s diagnosis, treatment, as well as any patient identifiers. Be sure to utilize your facility’s
approved patient data disposal systems.

PATIENT assessment PAGE 1

RNReport Card comes with 1 example page and 40 Individual pages. 1 Page is designated for 1 Patient. Below is and example of what you will find on page 1 of the patient information page.

  • Name / Room / Bed
  • Age
  • Sex
  • Med Times
  • MD / Service
  • Dx
  • Rhythm / Tele #
  • Admit Reason
  • IV / Date
  • Diet
  • Activity
  • Allergies
  • Daily Weight
  • Accucheck
  • Fall Precautions
  • Drips
  • Isolation
  • HX
  • Vitals
  • Notes

PATIENT assessment PAGE 2

Procedures

  • BC
  • CT Scan
  • CXray
  • Echo
  • EEG
  • EGD
  • EKG
  • MRCP
  • MRI
  • Pet Scan
  • Pulmonary
  • Stress Test
  • UA
  • UC /S
  • U/S
  • V Q Scan
  • X-Ray

assessment
Neuro (AA0X3, confused, disoriented, PERRLA, paralysis, pain, ambulation, gait)

Respiratory (wheezes, crackles, rhonchi, rales, stridor, trach, 02, IS, chest tube, cough, non/productive)

Cardio (pulses, HR, rhythm & character, capillary refill, edema, vascular access devices, apical S3, S4)

GI (soft, distended, BM, + BS, NG tube, N/V, flatus,
tube feeding, colostomy, ileostomy, incontinent )

GU (voiding, bladder distended, nephrostomy tube, Miami pouch, urine frequency, character, foley, incontinent.

Integumentary (edema, drsg, incision, temp, turgor, clammy, dry intact, fricition, TEDS, SCD, lesions, rashes)

Consults
Neuro, ENT, Optometry, Endocrine, Cardiac, Pulmonary, GI, Colorectal, GU, GYO, Nephrology, ID, Derm, Surgery, Anesthesia, Plastics, Oncology, Speech, Ortho, Spine, Pain, Wound Care,
RadOnc, Psych, Social Work

LAB VALUES REFERENCE PAGE 1

  • Sodium (Na+) 135 - 145 mmol / L
  • Potassium (K+) 3.5 - 5.2 mmol / L
  • Chloride (Cl- ) 95 - 110 mmol / L
  • Carbon dioxide (C02 ) 19 - 34 mmol / L
  • Anion Gap 6 - 22 mg / dL
  • Glucose 70 - 110 mg / dL
  • BUN 6 - 22 mg / dL
  • Creatinine 0.6 - 1.3 mg / dL
  • Glomer Filt Rat >60 ml/min
  • TBIL 0.1 - 1.1 mg/d
  • AST 10 - 40 U/L
  • Total Protein 5.5 - 8.7 g/dL
  • Albumin 3.2 - 5.0 g/dL
  • Calcium (Ca+) 8.7 - 10.5 mg/dL
  • ALT (SGPT) 7 - 55 U/L

LAB VALUES REFERENCE PAGE 2

  • WBC 3.5 - 9.6 mm3
  • RBC 3.8 - 5.2 M/uL
  • HGB 11.8 - 15.4 gm/dL
  • HCT 34.7 - 45.2 %
  • MCV 81.0 - 97.0 fl
  • MCH 26.0 - 34.0 pg
  • MCHC 28.0 - 37.0 gm/dL
  • RDW 11.5 - 15.0 %
  • Platelets 147 - 354 mm3
  • Neutrophil % 36 - 66 %
  • Lymphocyte % 23.0 - 43.0 %
  • Monocyte % 0.0 - 10.0 %
  • Eosinophil % 0.0 - 5.0 %
  • Basophil % 0.0 - 1.0 %
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