Emergency Department Nursing Report Sheet
Document patient care, assessments, and interventions during the emergency department visit.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Record Number
*
Date and Time of Admission
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Triage Level
*
Level 1 - Resuscitation
Level 2 - Emergent
Level 3 - Urgent
Level 4 - Less Urgent
Level 5 - Non-Urgent
Chief Complaint
*
Allergies (specify 'None' if no known allergies)
*
Vital Signs
*
Rows
Value
Time Recorded
Temperature
Pulse
Respiratory Rate
Blood Pressure
Oxygen Saturation
Nursing Assessment
*
Interventions Performed
*
IV Access
Medication Administration
Wound Care
Monitoring
Patient Education
Other
Medications Administered (list all with dose and time)
Physician Notified
*
Yes
No
Discharge or Transfer Details
*
Nurse's Name
*
Nurse's Signature
*
Submit Report
Submit Report
Should be Empty: