Daily Nursing Report

This document serves as a daily nursing report used to record patient observations, medications administered, and care activities performed during a nursing shift. It is intended to ensure reliable communication and continuity of care within the healthcare team.

Patient Information

• Patient Name: {patientName}
• Date of Birth: {dob}
• Patient ID: {patientId}
• Room Number: {roomNumber}
• Date of Report: {reportDate}

Vital Signs

Medications Administered

{#medications}

• {medicationName}: {dosage}, administered at {administrationTime}

{/medications}

Patient Observations

{#observations}

• Time: {observationTime} - {details}

{/observations}

Nursing Interventions

{#interventions}

• Time: {interventionTime} - {interventionDescription}

{/interventions}

Meals and Nutrition

Appetite: {appetiteStatus}

Food Intake Notes: {foodIntakeNotes}

Mobility and Toileting

Mobility Status: {mobilityStatus}

Toileting Needs: {toiletingDetails}

Additional Notes

{additionalNotes}

Shift Information

• Nurse's Name: {nurseName}
• Shift Time: {shiftTime}

{#hasFollowUp}

Follow-up Tasks

{followUpDetails}

{/hasFollowUp}

{^hasFollowUp}

No follow-up tasks documented at this time.

{/hasFollowUp}