Nursing Handoff Report
Nursing Handoff Report
Date: September 26, 2050
I. Patient Information
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Patient Name: Ernesto Murphy
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Patient ID: 123456
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Date of Birth: 01/15/1985
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Gender: Male
II. Admission Information
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Admitting Physician: Dr. Ena Cassin
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Date of Admission: 09/20/2050
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Admitting Diagnosis: Acute Pneumonia
III. Current Condition
Vital Signs:
|
Vital Sign |
Reading |
|---|---|
|
Temperature |
101°F |
|
Heart Rate |
88 bpm |
|
Respiratory Rate |
22 breaths/min |
|
Blood Pressure |
120/80 mmHg |
Current Status:
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The patient is alert and oriented but fatigued. Cough productive of green sputum. Oxygen saturation is 92% on room air.
IV. Treatment Plan
Medications Administered:
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Azithromycin: 500 mg IV daily
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IV Fluids: Normal Saline at 75 mL/hr
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Acetaminophen: 650 mg PO every 6 hours as needed for fever
Pending Procedures:
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Chest X-ray scheduled for later today to assess for any complications.
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Sputum culture results are pending.
V. Transfer Information
Transfer to: Room 202, Respiratory Care Unit
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Reason for Transfer: The patient requires close monitoring due to respiratory distress and ongoing treatment for pneumonia.
VI. Communication Notes
Concerns:
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Monitor for worsening respiratory status and ensure oxygen saturation levels remain above 92%.
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Ensure patient education regarding the importance of completing the antibiotic course.
Family Communication:
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The family was updated about the patient's condition and transfer. They are aware of the ongoing treatment plan.
VII. Summary of Handoff
Handoff to: Nurse Lowell Quizon
Contact Information for Further Queries:
If you have any questions or require further information, please feel free to reach out to me, Ena Cassin, at [Your Email], representing [Your Company Name]. You can also contact me at [Your Company Email].
This Nursing Handoff Report serves to ensure that all necessary information is communicated effectively to maintain continuity of care during the transfer of Ernesto Murphy to the Respiratory Care Unit. Please ensure all relevant details are followed up and any changes in patient condition are documented accordingly.
