Orders of Assembling Patients Chart

a. History sheet
b. Personal and social data
c. Order sheet
d. Doctor’s progress notes
e. Nurses notes
f. Vital sign sheet (graphics)
g. Intake and output recording sheet
h. Laboratory and other diagnostic reports

• Patients or relatives and friends of patients are not allowed to read the chart when necessary but can have access if allowed by patient.

Intake and out put
a. Intake: all fluids that is taken in to the body through the mouth, NG tube or parentrally
b. Output: all fluid that is excreted or put out of the body through the mouth. N/G tube, urethra, drainage tube or other route (GI-diarrhea, vomiting).

Purpose:
• To replace fluid losses
• To provide maintenance requirements
• To check for retention of body fluid

Fluid balance sheet
♦ 24 hrs the intake out put should be compared and the balance is recorded
Positive balance if intake >output
Negative balance if out put >intake

Study Questions
1. Explain at least three reasons for laboratory examination of urine.
2. Explain at least one reason for collecting specimens like sputum, blood or stool.
3. Mention purposes for sputum specimen collection.
4. Describe the process how to draw venous blood for laboratory investigation.
5. How can you obtain sterile urine specimen?
6. Differentiate between signs and symptoms.