ST.

MICHAEL’S COLLEGE
COLEGE OF NURSING

ENDORSEMENT FORM
Date: Shift: Total Census: Discharge:
Area: CI : Admission: Total Latest census:

VITAL SIGNS
NAME/ CC / AP IVF SPECIAL ENDORSEMENT MORNING AFTERNOON NOC
8AM 12NN 4PM 8PM 12AM 4AM
T T T T T T
P P P P P P
R R R R R R
BP BP BP BP BP BP
I I I
U U U
S S S
T T T T T T
P P P P P P
R R R R R R
BP BP BP BP BP BP
I I I
U U U
S S S
T T T T T T
P P P P P P
R R R R R R
BP BP BP BP BP BP
I I I
U U U
S S S

_______________________________ __________________________________ ____________________________________

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED
NAME
HEAD NURSING STUDENT CLINICAL INSTRUCTOR
CHARGE NURSE OF MCH
 ST. MICHAEL’S COLLEGE
COLEGE OF NURSING

DAILY PLAN OF ACTIVIES & time inventory

DATE/ SHIFT:__________________________
AREA:________________________________

DATE/TIM PLAN OF ACTIVIES DATE/ INVENTORY OF ACTIVIES

E TIME

_________________________________________ _________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL
INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING

ADMITTING DX: NURSES NOTES ADMITTING DX:

DATE/TIME/S NURSES NOTES/ NAME OF PT. DATE/TIME/S NURSES NOTES/ NAME OF PT.
HIFT HIFT
_________________________________________ _________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL
INSTRUCTOR
ST. MICHAEL’S COLLEGE
COLEGE OF NURSING

PATIENT ASSIGNMENT AND CENSUS

RM # NAME OF ADMITTING DX ASSIGNED RM # NAME OF ADMITTING DX ASSIGNED
PATIENT STUDENT PATIENT STUDENT

Date: Shift: Total Census: Discharge:

Area: CI : Admission: Total Latest census:

______________________________________ __________________________________ ____________________________________

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED
NAME
HEAD NURSING STUDENT CLINICAL INSTRUCTOR CHARGE NURSE OF MCH

ST. MICHAEL’S COLLEGE

COLEGE OF NURSING

Medication checklist
Date: Shift: Total Census: Discharge:
Area: CI : Admission: Total Latest census:

RM# NAME OF PATIENT NAME OF DRUGS TIME ROUTE OF NAME OF MCH SIGNATURE OF MCH
GIVEN ADMINISTRATION STAFF STAFF

______________________________________ __________________________________ ____________________________________

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED
NAME
STAFF NURSING STUDENT CLINICAL INSTRUCTOR CHARGE NURSE OF MCH

ST. MICHAEL’S COLLEGE

COLEGE OF NURSING

VITAL SIGNS SHEET

DATE/ SHIFT:__________________________ AREA:________________________________

PATIENT’S NAME ROO TIME TIME I/O U/S STUDENT NURSE

M # ASSIGNED
T P R BP T P R BP
Prepared by:__________________________ Noted by: ___________________________ Supervised
by:____________________________
TEAM LEADER CHARGE NURSE CLINICAL
INSTRUCTOR

ST. MICHAEL’S COLLEGE

COLEGE OF NURSING

Nurse’s daily evaluation

DATE/ SHIFT:__________________________ AREA:________________________________

WHAT DID I LEARN

TODAY

WHAT HINDERS MY
LEARNING

WHAT IS/ARE MY
MEMORABLE EVENTS I
HAD TODAY

WHAT I WANT TO LEARN

TOMORROW

MY PRAYER FOR TODAY

IS….

________________________________________ _________________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL INSTRUCTOR

ST. MICHAEL’S COLLEGE

COLEGE OF NURSING

IV MONITORING SHEET

DATE/ SHIFT:__________________________ AREA:________________________________

IVF Stock on
Level Time
STUDENT NURSE IVF Bottl Rat IV Time Cabinet
ROOM Left
#
PATIENT’S NAME ASSIGNED vol e # e
consume
TF
followe
d d up Receive
(ml) Endorse
d d
Prepared by:__________________________ Noted by: ___________________________ Supervised
by:____________________________
TEAM LEADER CHARGE NURSE CLINICAL
INSTRUCTOR

ST. MICHAEL’S COLLEGE

COLEGE OF NURSING

DIAGNOSTIC/LABORATORY STUDIES SHEET

DATE/ SHIFT:__________________________ AREA:________________________________

DATE
NAME OF INDICATION NORMAL ACTUAL SIGNIFICANCE OF THE
DONE
TEST/PROCEDURE VALUE RESULTS/FINDIN RESULTS/FINDINGS
GS
________________________________________ ________________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL
INSTRUCTOR

ST. MICHAEL’S COLLEGE

COLEGE OF NURSING

SUPERVISED SUPERVISION
DATE/ SHIFT:__________________________ AREA:________________________________

NAME OF NAME OF PATIENT DATE SUPERVISED BY REMARKS

PROCEDURE PERFORMED
Prepared by: Supervised by: Noted by:

________________________________________ ____________________________________ ___________________________________

SIGNATURE OVER PRINTED NAME OF STUDENT TEAM LEADER
CLINICAL INSTRUCTOR

ST. MICHAEL’S COLLEGE

COLEGE OF NURSING

HEALTH TEACHING PLAN(WARD CLASS)

DATE/ SHIFT:__________________________ AREA:________________________________

GOAL:
 LEARNING TIME
LEARNING
LEARNING OBJECTIVES LEARNING ACTIVITIES LEARNING OUTCOME
CONTENT ALLOTMENT

Prepared by:__________________________ Noted by: ___________________________ Supervised

by:____________________________
TEAM LEADER CHARGE NURSE CLINICAL
INSTRUCTOR

ST. MICHAEL’S COLLEGE

COLEGE OF NURSING

General/specific objectives

DATE/ SHIFT:__________________________ AREA:________________________________

GENERAL OBJECTIVES:

SPECIFIC OBJECTIVES:

________________________________________ ________________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL INSTRUCTOR

ST. MICHAEL’S COLLEGE

COLEGE OF NURSING

Requirements & attendance form

DATE/ SHIFT:_________________________
AREA:________________________________
 Requirements Attendance Remarks

Pr CS/
STUDENT NURSE SO DPA/TIS NDE Notes P
N DP K SS DRS 1 2 3
oj P
GO C D/L
A P
1 2 3 1 2 3 1 2 3 1 2 3 1 2 1 2 3

Prepared by:__________________________ Supervised

by:____________________________
TEAM LEADER CLINICAL INSTRUCTOR

ST. MICHAEL’S COLLEGE

COLEGE OF NURSING
 Digital reading summary

DATE/ SHIFT:__________________________ AREA:________________________________

SUMMARY:

REACTION:

________________________________________ ________________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL INSTRUCTOR

ST. MICHAEL’S COLLEGE

COLEGE OF NURSING

Discharge plan worksheet

DATE/ SHIFT:__________________________ AREA:________________________________

 A. DISCHARGE PLAN GIVEN TO: Patient  Family  Significant Others  Destination: Home 
Transfer  Others 
Date Instruction Given: ____________________ Given by: __________________________________________
B. DIET: Regular  Special  Specify:_________________________________
Special Instruction: __________________________________________________________________________________________________________________________________
C. INFORM PHYSICIAN for any observable signs/symptions of exacerbation or complication
Condition: _________________ S/Sx: ____________________________ Complication: ______________
S/Sx:_____________________________________
Name of Physician: ____________________________ Address: ________________________________ Contact Numbers:
___________________
D. SUPPORT SYSTEM: Family  Community  Specify: ________ Institutional  Specify:
____________________________
E. COPING MECHANISM (Psychological Adaptation to Wellness)
Strengths:_________________________________ Weaknesses: _________________________________________________
F. HEALTH TEACHING on specific lifestyle and environment modifications
Restful Periods  Smoke Avoidance  Alcohol Moderation  Stress Reduction  Special Instructions:
__________________________________
G. ACTIVITY LEVEL: Independent  Dependent  Activities Allowed: ___________________ Activities Restricted:
_______________________
H. REACTION AND PRECAUTIONS TO DRUGS. (Refer to next Item)
Specific Instructions: ________________________________________________________________________________________________________________________________
I. GIVE HOME MEDICATIONS AS ORDERED (use separate sheet for this item only)
Medication Dose Frequency Precaution to Observe and Report
________________ _______ ______________ ______________________________________________________
________________ _______ ______________ ______________________________________________________
________________ _______ ______________ __________________________________
J. EXPECTED DATE OF FOLLOW UP CARE: Referral Given  Not needed  Specifics:
_____________________________________
K. ACTUAL DISCHARGE: Date and Time___________________ Mode: ___________________ Destination: ______ Condition on Discharge:
________________________

________________________________________ ________________________________________________
SIGNATURE OVER PRINTED NAME OF STUDENT CLINICAL INSTRUCTOR

ST. MICHAEL’S COLLEGE

 COLEGE OF NURSING

Kardex

DATE/ SHIFT:_________________________ AREA:________________________________

Date Date Date Date Date Special

Treatments Medications IV Fluids Laboratory
Procedures

Prepared by:__________________________ Noted by: ___________________________ Supervised

by:____________________________
TEAM LEADER CHARGE NURSE CLINICAL
INSTRUCTOR