Download Template for Sending Units` Report

Hamilton Health Sciences
Cardiac and Vascular Program
Heart Investigation Unit
Template for Sending Units’ Report
Name of Nurse Calling Report: ___________________________
Patient’s Name, Date of
Birth
Sending Hospital & Unit
Reason for procedure
Monitored/Non-Monitored
Allergies/Alerts
(FRI/MRSA)
Medications:
 ASA

Clopidogrel (Plavix)
 Anticoagulants
 Diabetic Meds
Bloodwork:
 INR
 K+
 Crt
 Hgb/Platelets
 WBC
 BS
IV’s Infusing (solution,
medication and rate)
 #1
 #2
 #3
Previous cardiac cath/PCI
and/or cardiac surgery
(date & hospital
performed)
Food/drink last taken
Discharge Plans (follow-up
appts booked,
prescriptions)
Family issues/concerns
Transfer checklist
complete
September 13, 2007
Hamilton Health Sciences
Cardiac and Vascular Program
Heart Investigation Unit
Template for Sending Units’ Report
Patient’s Name, Birth date
Allergy/Alert Updates
HIU Procedure Performed:
 Cath
 PCI
 Stents (type,#,location)
 Other
Complications
Cath Findings/Medical Plan
Medications Given:
 ASA
 Clopidogrel
 Adjunctive Therapy
 Anticoagulants
 Antiarrhythmics
 Others
IV’s (solutions, medications
and rate):
 #1
 #2
 #3
Monitored/Non-monitored
& why
Procedure Site:
 Closure device
 Sheath removed at;
(ambulation time)
 Presence/absence of
bruits
Family Issues/Concerns
Prescriptions Given:
Patient Education:
 Closure Device card
 Clopidogrel
Ambulance booking
September 13, 2007