Nursing NR 325 ISBAR HECTOR GOMEZ- Chamberlain College of Nursing

I Your Name: Your Title: Reason for Being There:
INTRODUCE
YOURSELF
Patient:
Hi
Age:

Gender:
Height/Weight:
S Allergies:
SITUATION Code status:
Privacy Code:
Time:
Attending Physician:
Patient Chief Complaint:
Chief Informant: Family History:


Current Medications: Social History:
Past Medical History:

B
BACKGROUND


VITAL SIGNS:
B/P HR RR TEMP

A
ASSESSMENT
FALLS RISK IV Fluids:
IV Site: Accu check:
Y N
ISOLATION Isolation Precautions: Y N Contact

HEENT




RESPIRATORY




CARDIOVASCULAR




NEUROLOGICAL




GI/GU
I&O


MUSCULOSKELETAL




INTEGUMENTARY





LYMPHATIC