PATIENT NAME:

[PATIENT'S NAME]

ROOM NUMBER:

[ROOM NUMBER]

DATE/TIME:

[DATE AND TIME OF COMMUNICATION]

SHIFT:

[SHIFT: DAY/NIGHT]

REPORTING NURSE:

[REPORTING NURSE'S NAME]

RECEIVING NURSE:

[RECEIVING NURSE'S NAME]

CONDITION CHANGE:

[BRIEF DESCRIPTION OF THE CHANGE IN PATIENT CONDITION]

MEDICAL HISTORY:

[BRIEF OVERVIEW OF PATIENT'S MEDICAL HISTORY]

ALLERGIES:

[LIST OF PATIENT'S ALLERGIES]

MEDICATIONS:

[LIST OF CURRENT MEDICATIONS AND DOSAGES]

TREATMENTS:

[SUMMARY OF RECENT TREATMENTS OR PROCEDURES]

DIAGNOSTIC TESTS:

[PENDING OR RECENT DIAGNOSTIC TESTS]

VITAL SIGNS:

[CURRENT VITAL SIGNS]

SYMPTOMS:

[DESCRIPTION OF ANY SYMPTOMS OBSERVED]

RESPONSE TO TREATMENT:

[PATIENT'S RESPONSE TO CURRENT TREATMENT]

PAIN LEVEL:

[PATIENT'S CURRENT PAIN LEVEL, IF APPLICABLE]

CONCERNS:

[ANY SPECIFIC CONCERNS REGARDING THE PATIENT'S CONDITION]

ACTION REQUIRED:

[RECOMMENDED ACTIONS OR INTERVENTIONS]

MEDICATION CHANGES:

[PROPOSED CHANGES TO MEDICATIONS OR DOSAGES]

FOLLOW-UP:

[INSTRUCTIONS FOR FOLLOW-UP CARE OR MONITORING]

CONSULTATIONS NEEDED:

[ANY NECESSARY CONSULTATIONS OR REFERRALS]

NOTES:

[ADDITIONAL NOTES OR INFORMATION]