EXAMPLE OF END OF DAY REPORT

New Admissions:

-Rm 202A J. Doe: Will see twice a week in RHIP for high risk/diagnosis of CHF. Recommend daily weights and IS Q2 while awake and PRN 10 breaths each time.

-Rm 210A B. Smith: Will see once a week in RHIP for low risk Pneumonia and CHF. Recommend weights 3 times a week due to CHF risk factors. IS Q2 while awake and PRN 10 breaths each time.

-Rm 300A A. Jones: Will see twice a week in RHIP for high risk pneumonia with diagnosis and high risk CHF with diagnosis. Patient also has COPD and will admit to pulmonary rehab to be seen twice a week. Recommend daily weights due to CHF diagnosis. Recommend DuoNeb QID and PRN for pneumonia diagnosis. Recommend IS Q2 while awake and PRN 10 breaths each time.

Follow Ups:

-Rm 400A B. Ford: seen twice a week in RHIP for CHF diagnosis. Resident had 4 lb. weight gain in 24 hours. Recommend MD to be notified with possible increase in diuretic.

-Rm 500A P. Floyd: seen twice a week in RHIP for pneumonia diagnosis. Breath sounds changed from clear bilat to L. lower lobe inspiratory wheeze. Recommend MD to be notified and to increase neb treatment to Q4 and PRN. Recommend chest xray.

Pulmonary Rehab:

-Rm 205A K. Davis: seen in pulmonary rehab. Resident completed 6 min walk without resting. HR, RR, BP, SpO2 all stable pre and post exercise. Also, seeing resident in RHIP twice a week. No recommendations.

D/C:

-Rm 350A W. Nelson has met 30 day length of stay. No respiratory issues or concerns. Will D/C from RHIP.

-Rm 450A W. Jennings: has met 30 day length of stay. Resident continues to have dyspnea at rest with a recent pneumonia diagnosis. Would like to continue to see resident as a RT complex. Please sign the request for RT services if DON agrees.

I will be back on “DATE” at ”TIME”. Please email me if you have any questions! Thanks!

RT Name and email address