Patient Data Organizer

PATIENT INFORMATION & ALLERGIES

PATIENT NAME

AGE / DOB

MRN / PATIENT ID

ROOM / BED

ADMISSION DATE

ADMITTING DIAGNOSIS

ALLERGIES:

ACTIVE MEDICAL PROBLEMS

CURRENT VITAL SIGNS & BASELINE

Vital Sign	Current	Baseline (Admission)	Normal Range	Status
Temperature			98.6°F
Pulse			60-100
Respirations			12-20
Blood Pressure			<120/80
O2 Saturation			95-100%
Pain Level			0

CURRENT MEDICATIONS

RECENT LAB VALUES (WITH NORMAL RANGES)

Medication Name	Dose	Route	Frequency	Key Nursing Considerations

DEVICES, LINES, & SPECIAL EQUIPMENT

Lab Test	Result	Normal Range	Status	Significance / Nursing Action

CODE STATUS & ADVANCE DIRECTIVES

CODE STATUS

HEALTHCARE POA

GOALS OF CARE

PROVIDER & CONTACT INFORMATION

ATTENDING PROVIDER

PHONE / PAGER

SHIFT ASSIGNMENT

TODAY'S SHIFT NOTES & PRIORITY CONCERNS

QUICK REFERENCE CHECKLIST

Device / Line	Insertion Date	Location / Size	Output / Function / Notes

Reviewed chart	Checked allergies
Reviewed medications	Identified critical values
Took vital signs	Assessed pain
Reviewed labs	Checked orders