Nurse Handoff Report
Nurse Handoff Report
I. Patient Information
1. Demographics
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Patient Name: John Doe
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Age: 65
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Gender: Male
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Unit: Cardiology
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Room Number: 205
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Admission Date: January 1, 2050
2. Medical History
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Primary Diagnosis: Congestive Heart Failure
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Allergies: Penicillin
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Past Medical History: Hypertension, Diabetes
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Surgeries: Appendectomy (2035), Knee Replacement (2040)
II. Current Status
1. Vital Signs
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Temperature: 98.6°F
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Heart Rate: 78 bpm
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Blood Pressure: 120/80 mmHg
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Respiratory Rate: 16 breaths per minute
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Oxygen Saturation: 98%
2. Lab Results
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WBC: 7.0 x 10^3/uL
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Hemoglobin: 14 g/dL
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Platelets: 250 x 10^3/uL
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Sodium: 140 mEq/L
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Potassium: 4.0 mEq/L
3. Medications
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Aspirin: 81mg daily
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Insulin: 10 units before meals
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Lasix: 20mg twice daily
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Lisinopril: 10mg daily
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Metformin: 500mg twice daily
4. Nursing Observations
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Overall condition: Stable
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Pain Level: 2 on a scale of 1-10
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Alertness: Alert and oriented
III. Care Plan
1. Goals
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Maintain stable vital signs
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Manage blood glucose levels
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Ensure patient comfort
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Prevent infections
2. Interventions
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Administer medications as per schedule
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Monitor glucose levels before meals
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Conduct daily assessments
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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]