Free Nurse Shift Report

[Your Company Name]

[Your Name]

Date: February 12, 2051

I. Patient Information

A. General Information

• Patient Name: John Doe

• Age: 72

• Room Number: 204

• Admission Date: January 5, 2051

B. Medical History

• Diabetes

• Hypertension

• Past surgeries: Appendectomy (2040)

II. Shift Summary

A. Observations

Patient exhibited stable vital signs throughout the shift. Reports of occasional dizziness were noted.

B. Medications Administered

• Insulin - 10 units at 8:00 AM

• Lisinopril - 20 mg at 9:00 AM

• Metformin - 500 mg at 12:00 PM

III. Nursing Care

A. Interventions

• Assisted with morning hygiene and dressing

• Monitored blood glucose levels pre and post meals

• Provided dietary recommendations per physician's orders

B. Patient Education

• Discussed symptoms of low and high blood sugar

• Emphasized the importance of medication adherence

• Reviewed proper use of a glucometer

IV. Upcoming Care Needs

• Monitor blood pressure every 4 hours

• Administer evening medications at 6:00 PM

• Prepare patient for a scheduled MRI at 11:00 AM, February 13, 2051

V. Communication

Reported observations and upcoming care needs to the oncoming nurse, Sarah Smith, at shift handover.

This Nurse Shift Report was officially written/prepared/created by: [Your Name]

Report Templates @ Template.net