Nurse Handoff Report

Nurse Handoff Report


I. Patient Information

1. Demographics

  • Patient Name: John Doe

  • Age: 65

  • Gender: Male

  • Unit: Cardiology

  • Room Number: 205

  • Admission Date: January 1, 2050

2. Medical History

  • Primary Diagnosis: Congestive Heart Failure

  • Allergies: Penicillin

  • Past Medical History: Hypertension, Diabetes

  • Surgeries: Appendectomy (2035), Knee Replacement (2040)

II. Current Status

1. Vital Signs

  • Temperature: 98.6°F

  • Heart Rate: 78 bpm

  • Blood Pressure: 120/80 mmHg

  • Respiratory Rate: 16 breaths per minute

  • Oxygen Saturation: 98%

2. Lab Results

  • WBC: 7.0 x 10^3/uL

  • Hemoglobin: 14 g/dL

  • Platelets: 250 x 10^3/uL

  • Sodium: 140 mEq/L

  • Potassium: 4.0 mEq/L

3. Medications

  • Aspirin: 81mg daily

  • Insulin: 10 units before meals

  • Lasix: 20mg twice daily

  • Lisinopril: 10mg daily

  • Metformin: 500mg twice daily

4. Nursing Observations

  • Overall condition: Stable

  • Pain Level: 2 on a scale of 1-10

  • Alertness: Alert and oriented

III. Care Plan

1. Goals

  • Maintain stable vital signs

  • Manage blood glucose levels

  • Ensure patient comfort

  • Prevent infections

2. Interventions

  • Administer medications as per schedule

  • Monitor glucose levels before meals

  • Conduct daily assessments

  • Provide patient education on medication

IV. Additional Notes

Ensure timely follow-ups with the cardiologist. Verify all medication dosages with the pharmacy. Maintain clear communication with the patient's family regarding care updates.

V. Contact Information

Prepared by: [Your Name]

Contact Email: [Your Email]

Company: [Your Company Name]

Website: Your Company Website]

Social Media: [Your Company Social Media]

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