Free 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]

Report Templates @ Template.net