Sri Venkateshwara Multi-Speciality Hospital · Kukatpally, Hyderabad · 60 beds
MG
Nursing — my shift
Mary Grace · Staff Nurse · 08:00–20:00, Sat 18 Jul 2026 · 7 beds across General & Semi-Private. ICU IC-01/02/03 are handed over separately by the ICU nurse.
Overdue right now
4
▲ oldest is 2 h 47 m late
Due by 11:17 (next 30 min)
4
2 of them are both at GM-05
My patients this shift
7
of the ward's 42 inpatients
Tasks charted
38 / 61
2 h 47 m into a 12 h shift
Online · last synced 12 s ago
Queued on this tablet: 0
Charting never blocks on the network — entries are written locally first, then synced.
Overdue
Sorted by how late, not by bed number
4 overdue
10:1235 min late
Critical lab value — read-back not documented
Lakshmi Devi · GF-01 · 58F · serum K 5.9 mmol/L phoned by Prasad (Lab) at 10:12 · known CKD 3a
09:301 h 17 m late
Dose not documented — Tab. Telmisartan 40 mg, oral
Lakshmi Devi · GF-01 · once daily · dispensed by Ravi Teja on indent PH-2026-0718-14
10:0047 min late
Post-dose BP recheck not charted
Venkatesh Naidu · GM-01 · 44M · Day 2 hypertension · Amlodipine 5 mg given 08:05 · Dr. K. Ramesh asked for a 2-hour recheck
08:002 h 47 m late
Braden pressure-sore reassessment (48-hourly)
G. Vijaya Lakshmi · SP-03 · 61F · Day 5 · limited mobility · last scored 16 Jul 08:00
Next 30 minutes
Due between now and 11:17
11:00in 13 min
Inj. Ceftriaxone 1 g IV — 12-hourly
B. Srinu · GM-05 · 67M · post-op TKR Day 4 · Dr. P. Anil Kumar · previous dose 23:00, given by night duty nurse
11:00in 13 min
Surgical wound dressing change + photo
B. Srinu · GM-05 · right knee midline incision · last changed 17 Jul 11:00 · same bedside visit as the Ceftriaxone above
11:00in 13 min
Inj. Enoxaparin 40 mg SC — DVT prophylaxis
K. Narayana · SP-01 · 52M · Day 2 · Dr. P. Anil Kumar
11:15in 28 min
IV bag change — NS 0.9% 500 ml
Mohd. Irfan · GM-03 · 32M · Day 1 fever · 90 ml left at 150 ml/hr, empties ≈ 11:23
✦
Round order for the next half hour
Draft — awaiting approval
Two of the four tasks due are both at GM-05. Grouped into one bedside visit, this round is 3 stops instead of 4 — the Ceftriaxone and the dressing together, then SP-01, then GM-03 before its bag runs at 11:23. The overdue read-back on GF-01 sits on the way from SP-01 to GM-03.
✦ Ordered from the charted due times, bed geography (GM → GF → SP corridor) and the infusion rate already recorded. It changes no dose, no route and no time — only the sequence you walk.
My beds — 7 patients
Tasks column is charted / planned for this 12-hour shift
Show
| Next due | Bed | Patient | Why they are in | Watch | Tasks |
|---|---|---|---|---|---|
| 10:12 · 35 m late | GF-01 | Lakshmi Devi 58F · Day 3 · Dr. K. Ramesh |
T2DM, HbA1c 8.4% · CKD 3a (eGFR 44) Metformin 1000 BD · Telmisartan 40 OD · Pregabalin 75 HS |
Allergy: Penicillin, Sulfa K 5.9 phoned 10:12 · read-back due |
6 / 10 |
| 10:00 · 47 m late | GM-01 | Venkatesh Naidu 44M · Day 2 · Dr. K. Ramesh |
Hypertension — uncontrolled on admission Amlodipine 5 OD · Metoprolol 25 BD |
BP recheck not charted | 5 / 8 |
| 08:00 · 2 h 47 m late | SP-03 | G. Vijaya Lakshmi 61F · Day 5 · Dr. K. Ramesh |
Post-seizure observation, limited mobility Levetiracetam 500 BD · Amlodipine 5 OD · Atorvastatin 20 HS |
Braden overdue 08:00 Amlodipine held — BP 96/58 |
4 / 7 |
| 11:00 · in 13 min | GM-05 | B. Srinu 67M · Day 4 · Dr. P. Anil Kumar |
Post-op total knee replacement (right) Cleared for discharge 19 Jul |
Morse 60 — high fall risk Foley day 4 · removal criteria met |
6 / 9 |
| 11:00 · in 13 min | SP-01 | K. Narayana 52M · Day 2 · Dr. P. Anil Kumar |
Post-op fracture fixation Enoxaparin 40 SC OD · Diclofenac 50 BD |
Refused 09:00 Diclofenac Cannula day 3 · VIP score 2 |
5 / 8 |
| 11:15 · in 28 min | GM-03 | Mohd. Irfan 32M · Day 1 · Dr. K. Ramesh |
Fever 4 days, under investigation Azithromycin 500 OD · Inj. Paracetamol 1 g Q8H · NS 150 ml/hr |
4-hourly temps Blood culture with Prasad, pending |
7 / 10 |
| 12:00 · in 1 h 13 m | GF-03 | Padma Sree 28F · antenatal 24 w · Dr. Sunitha Rao |
Observation, pre-eclampsia workup Labetalol 100 BD · Calcium + Vit D3 OD |
4-hourly BP + urine protein FHR check with each BP |
5 / 9 |
38 of 61 planned tasks charted — that is the sum of the Tasks column above. Bed status, transfers and discharges live in IPD → Bed Board; this screen is only the work assigned to me.
SBAR handover — 7 beds
Situation · Background · Assessment · Recommendation
Since 08:00 you have charted 22 vitals entries, given or documented 10 medication administrations, written 9 nursing notes, received 4 doctor orders and acknowledged 2 lab results. Everything the night nurse needs is already in those 47 events — it has simply never been assembled before.
Handover I received at 08:00
From the night duty nurse · signed 07:58, countersigned by me 08:07
S — 7 beds, no overnight transfers. GM-03 spiked to 102.4 °F at 02:00. SP-03 hypotensive at the 06:00 round.
B — GM-05 Day 4 post-op TKR, discharge planned 19 Jul. GF-01 Day 3, K awaited. GF-03 antenatal 24 w on 4-hourly BP.
A — GM-03 responded to Inj. Paracetamol 1 g at 06:00, temp 101.1 °F by the end of the round. SP-03 BP 96/58 at 07:55 — the morning Amlodipine was left for the day nurse to decide against the order's hold parameter. GM-05 slept through, Foley drained 720 ml overnight.
R — Repeat serum K on GF-01 (sample went with Prasad at 07:20). Watch GM-03 4-hourly. SP-03 recheck BP before any antihypertensive.
Countersigning is what makes a handover a record rather than a conversation — both nurses are named, and the pair is in the tamper-evident audit log.
What changed on my shift
Recorded events, newest first
10:45
GM-03 — IV NS 500 ml down to 90 ml at 150 ml/hr. Next bag prepared, change by 11:15.
10:30
GM-03 — Temp 100.6 °F, pulse 98, RR 20, SpO₂ 97% room air, BP 120/76. Fifth charted set in 12 h.
10:15
GM-05 — Pain 2/10 at rest, 4/10 on movement (was 4/10 and 6/10 at 08:00, Paracetamol given 08:15).
10:12
GF-01 — Prasad (Lab) phoned serum K 5.9 mmol/L. Read-back not yet documented. open
10:00
GF-03 — BP 138/88, urine protein trace, FHR 146. Dr. Sunitha Rao's 4-hourly order satisfied.
09:40
GM-05 — Physiotherapy: knee flexion 75° (70° on Day 3), ambulated 20 m with walker.
09:04
SP-01 — Tab. Diclofenac 50 mg refused — patient reports gastric burning. Dr. P. Anil Kumar informed 09:08.
08:02
SP-03 — 08:00 Amlodipine held: BP 96/58 at 07:55, below the hold parameter written into the order. Dr. K. Ramesh informed.
For the incoming nurse to watch
Built from recorded orders and your ward's own thresholds
GF-01 Lakshmi Devi — repeat serum K at 22:00 (Dr. K. Ramesh, order recorded 10:55). Hourly urine output charting. Penicillin + Sulfa allergy
GM-03 Mohd. Irfan — 4-hourly temps; Inj. Paracetamol 1 g IV at 14:00 and 22:00 as charted; blood culture result still pending with the lab.
SP-01 K. Narayana — analgesia refused this morning; Dr. P. Anil Kumar is reviewing the order. Cannula day 3, VIP score 2 — ward policy resites at 2.
SP-03 G. Vijaya Lakshmi — Amlodipine held this morning; recheck BP before the 20:00 dose. 2-hourly position change and heel offloading.
Each line points at a recorded order or a recorded threshold breach. HOS does not decide which patient is sickest — that ranking is a clinical judgement and it stays with you.
Handover completeness
The five things audits find missing
Allergies carried over ✓
Lines & drains listed ✓
Pending investigations ✓
Pending doctor reviews ✓
Outstanding tasks: 4 open
✦
SBAR handover — drafted from 47 events between 08:00 and 10:47
Draft — awaiting approval
✦ Assembled from 22 vitals entries, 10 medication administrations, 9 nursing notes, 4 doctor orders and 2 lab results — 47 events, every line traceable to one of them. No value here was estimated or carried forward.
This used to be 30–40 minutes of writing after a 12-hour shift, mostly unpaid. The draft was ready before you started.
Doses scheduled 08:00–20:00
21
across my 7 beds
Given so far
8
all 8 barcode-verified
Refused / held
2
1 refused, 1 held — both with a reason
Near-misses caught
1
wrong patient, blocked at the scan
Bedside administration — scan to verify
Wristband → drug → five rights → give. Works offline; the check runs on the tablet.
STEP 1
Scan patient wristband
Not scanned
STEP 2
Scan drug label
Not scanned
STEP 3
Five rights
Waiting for both scans
Wristbands are printed at admission on the ward label printer, so this works on a ₹9,000 Android tablet with a ₹1,800 USB scanner — no wifi needed for the check itself (research/11: label/thermal printer support, low-end Android, graceful degradation).
eMAR — this shift's administration record
08:00–20:00 · 21 scheduled doses · time first, because late is the thing that matters
Filter
| Due | Status | Patient · bed | Drug · dose · route | Verified | Recorded by |
|---|---|---|---|---|---|
| 08:00 | Given 08:05 | Venkatesh Naidu · GM-01 | Tab. Amlodipine 5 mg · oral | Barcode ✓ | Mary Grace |
| 08:00 | Given 08:06 | Venkatesh Naidu · GM-01 | Tab. Metoprolol 25 mg · oral | Barcode ✓ | Mary Grace |
| 08:00 | Given 08:14 | B. Srinu · GM-05 | Tab. Pantoprazole 40 mg · oral | Barcode ✓ | Mary Grace |
| 08:00 | Given 08:15 | B. Srinu · GM-05 | Tab. Paracetamol 650 mg · oral | Barcode ✓ | Mary Grace |
| 08:00 | Given 08:20 | Lakshmi Devi · GF-01 | Tab. Metformin 1000 mg · oral | Barcode ✓ | Mary Grace |
| 08:00 | Given 08:30 | Padma Sree · GF-03 | Tab. Labetalol 100 mg · oral | Barcode ✓ | Mary Grace |
| 08:00 | Given 08:31 | Padma Sree · GF-03 | Tab. Calcium + Vit D3 · oral | Barcode ✓ | Mary Grace |
| 08:00 | Given 08:40 | G. Vijaya Lakshmi · SP-03 | Tab. Levetiracetam 500 mg · oral | Barcode ✓ | Mary Grace |
| 08:00 | Held 07:58 | G. Vijaya Lakshmi · SP-03 | Tab. Amlodipine 5 mg · oral Reason: BP 96/58 at 07:55 — order says hold if systolic < 100. Dr. K. Ramesh informed 08:02. | Barcode ✓ | Mary Grace |
| 09:00 | Refused 09:04 | K. Narayana · SP-01 | Tab. Diclofenac 50 mg · oral Reason: patient reports gastric burning, declined. Dr. P. Anil Kumar informed 09:08; analgesia under review. | Barcode ✓ | Mary Grace |
| 09:30 | Not documented · 1 h 17 m | Lakshmi Devi · GF-01 | Tab. Telmisartan 40 mg · oral | — | |
| 11:00 | Due in 13 min | B. Srinu · GM-05 | Inj. Ceftriaxone 1 g · IV | — | on the trolley |
| 11:00 | Due in 13 min | K. Narayana · SP-01 | Inj. Enoxaparin 40 mg · SC | — | on the trolley |
| 12:00 | Scheduled | Mohd. Irfan · GM-03 | Tab. Azithromycin 500 mg · oral | — | — |
| 14:00 | Scheduled | B. Srinu · GM-05 | Tab. Paracetamol 650 mg · oral | — | — |
| 14:00 | Scheduled | Mohd. Irfan · GM-03 | Inj. Paracetamol 1 g · IV | — | — |
| 20:00 | Scheduled | Venkatesh Naidu · GM-01 | Tab. Metoprolol 25 mg · oral | — | — |
| 20:00 | Scheduled | B. Srinu · GM-05 | Tab. Paracetamol 650 mg · oral | — | — |
| 20:00 | Scheduled | Lakshmi Devi · GF-01 | Tab. Metformin 1000 mg · oral | — | — |
| 20:00 | Scheduled | Padma Sree · GF-03 | Tab. Labetalol 100 mg · oral | — | — |
| 20:00 | Scheduled | G. Vijaya Lakshmi · SP-03 | Tab. Levetiracetam 500 mg · oral Recheck BP before the held Amlodipine is re-offered. | — | — |
08:00 round · 8 given, 1 held
09:30 · 0 of 1
11:00 round · 0 of 2, due now
12:00 · 1 · 14:00 · 2 · 20:00 · 5
8 given + 1 held + 1 refused + 1 not documented + 10 still to come = 21.
Where the drug came from
Administration is recorded here; stock, batch and billing stay in Pharmacy
Ravi Teja dispensed today's ward indent at 07:20 — 24 units against 21 scheduled doses, 3 kept as ward float. Each unit carries the batch barcode this screen scans, so the administration record and the batch record are the same fact recorded twice.
The held Amlodipine and the refused Diclofenac go back to Pharmacy as returns, not as waste — Pharmacy → Stock & Batches reconciles them tonight. HOS does not rebuild dispensing here; it posts the administration back so the two ledgers agree.
Issued to this ward today
24
units · indent PH-2026-0718-14 at 07:20
Administered and charted
8
consumed — in a patient
On the ward, returnable
2
1 held · 1 refused
Cannot be placed
1
until the 09:30 dose is charted
Ward floor stock — where every issued unit is right now
Built from the eMAR, not from a second count · Ward & ICU · 10:47 AM
Indent PH-2026-0718-14
| Movement | Units | Where it physically is | Recorded by |
|---|---|---|---|
| Issued in — dispensed against today's indent 21 against scheduled doses + 3 ward float | +24 | arrived on the ward 07:20 | Ravi Teja · Pharmacy |
| Administered and charted 08:00 round · barcode verified | −8 | In a patient | Mary Grace |
| Held — dose not given Amlodipine 5 mg · G. Vijaya Lakshmi · SP-03 | 1 | On the ward · returnable | Mary Grace |
| Refused — patient declined Diclofenac 50 mg · K. Narayana · SP-01 | 1 | On the ward · returnable | Mary Grace |
| Not documented Telmisartan 40 mg · Lakshmi Devi · GF-01 · due 09:30 | 1 | Cannot be placed | — |
| Scheduled, still to come 11:00 · 12:00 · 14:00 · 20:00 rounds | 10 | on the trolley | — |
| Ward float, unallocated Held back for an unscheduled order | 3 | in the ward cupboard | Ravi Teja · Pharmacy |
| Balance | 24 | 8 consumed + 16 still on the ward — ties to the 24 issued | |
8 given + 1 held + 1 refused + 1 not documented + 10 to come + 3 float = 24. The same arithmetic the Medication Round footer shows for doses, carried through to units — because a dose the ward did not give is a unit the ward still holds.
✦
One unit cannot be placed until the 09:30 Telmisartan is charted
Reference alert · your call
The eMAR has shown Tab. Telmisartan 40 mg for Lakshmi Devi (GF-01) as not documented for 1 h 17 m. Until it is charted, this ledger cannot say whether that tablet is in the patient or still in the trolley, so it is counted as neither.
This is a stock question, not a conduct question. HOS does not decide what happened — the trolley count settles it, and charting the dose closes both records at once.
This is a stock question, not a conduct question. HOS does not decide what happened — the trolley count settles it, and charting the dose closes both records at once.
Sources: eMAR row for 09:30 · indent PH-2026-0718-14 unit count · ward float register. No stock figure was adjusted and no return was raised.
Crash cart — sealed, and therefore unopened since 14 Jul
Seal check each shift · full contents check monthly, per this ward's own policy
Seal intact
Seal number
SL-2026-0714
Sealed
14 Jul, 06:00 · Sister Vasavi
Seal verified this shift
08:10 today · Mary Grace
Next seal check due
20:00 · Sister Latha
A sealed cart is an unopened cart. The seal proves nobody has taken anything from it — it does not prove that what is inside is still in date. The expiry register below knows the contents even though the seal has not been broken since 14 Jul.
| Days left | Contents (unopened) | Qty | Expiry |
|---|---|---|---|
| 22 | Inj. Adenosine 6 mg | 2 | 09/08/2026 |
| 44 | Inj. Atropine 0.6 mg | 5 | 31/08/2026 |
| 74 | Inj. Amiodarone 150 mg | 2 | 30/09/2026 |
| 135 | Inj. Adrenaline 1 mg | 5 | 30/11/2026 |
| 197 | Inj. Sodium bicarbonate 7.5% | 2 | 31/01/2027 |
| 225 | Inj. Dextrose 25% | 2 | 28/02/2027 |
✦
Adenosine expires in 22 days — inside the cart, behind an intact seal
Draft — awaiting approval
Both Adenosine ampoules expire on 09 Aug 2026. The cart is not due to be opened before then, so on current practice the seal would be broken in an emergency and the ampoule found expired at the moment it was needed.
A replacement indent is drafted for Pharmacy. Breaking the seal to swap them also requires a new seal number and a two-nurse re-check — both recorded against the nurses who do it, not against this draft.
A replacement indent is drafted for Pharmacy. Breaking the seal to swap them also requires a new seal number and a two-nurse re-check — both recorded against the nurses who do it, not against this draft.
Sources: crash cart contents register (sealed 14 Jul, SL-2026-0714) · batch expiry from Pharmacy · this ward's own monthly contents-check policy. Nothing was ordered and no seal was broken.
Schedule H1 ward count
Two nurses, every shift · statutory
Register agrees
| Drug | Register | Counted | Result |
|---|---|---|---|
| Tab. Tramadol 50 mg Schedule H1 · ward float | 12 | 12 | Agrees |
| Inj. Pentazocine 30 mg Schedule H1 · ward float | 4 | 4 | Agrees |
✦
10:40 count assembled from the register — needs a second nurse
Draft — awaiting approval
Physical count matches the register on both lines. Counted by Mary Grace at 10:40. A Schedule H1 count signed by one nurse is not a count — the second signature is the control, so this stays a draft until the witnessing nurse confirms it.
Sister Vasavi is on this ward for the rest of the shift.
Sister Vasavi is on this ward for the rest of the shift.
Sources: ward Schedule H1 register · physical count at 10:40. HOS did not count anything; it laid the register beside what the nurses recorded.
B. Srinu's discharge returns include Tramadol, which needs a register reversal rather than a plain return. That reversal is raised where the register lives — Pharmacy → Stock & Batches. HOS keeps one number in one place.
Chart vitals — Mohd. Irfan · GM-03
32M · Day 1 · fever under investigation · last set 10:30
last 100.6
last 98
last 120
last 76
last 20
last 97
last 2
last 112
Saves locally first. A set is 8 taps typed, 1 tap by voice.
Temperature & pulse — last 12 hours
Five charted sets · the direction is the finding, not any single reading
Temperature °F
Pulse bpm (scaled 90–120)
| Time | Temp °F | Pulse | RR | SpO₂ | BP | Charted by |
|---|---|---|---|---|---|---|
| 10:30 | 100.6 | 98 | 20 | 97% | 120/76 | Mary Grace |
| 08:10 | 100.9 | 100 | 20 | 97% | 118/74 | Mary Grace |
| 06:00 | 101.1 | 102 | 21 | 96% | 116/72 | Night duty nurse |
| 02:00 | 102.4 | 112 | 22 | 95% | 114/70 | Night duty nurse |
| 22:00 | 101.8 | 108 | 22 | 96% | 118/74 | Night duty nurse |
On paper this is five rows on a folded observation chart, and the shape is invisible until someone redraws it. Here the shape is the default view — that was the founder's stated pain point, "missing trends".
Intake & output — Mohd. Irfan
This shift, 08:00 → 10:47
| Intake | ml | Output | ml |
|---|---|---|---|
| IV NS 0.9% @ 150 ml/hr | 410 | Urine (measured) | 420 |
| Oral fluids | 350 | Vomit | 0 |
| IV flush with medication | 20 | Drain | 0 |
| Total in | 780 | Total out | 420 |
780 in − 420 out = +360 ml this shift. Running 24-hour balance +860 ml, charted hourly. Insensible losses are not estimated here — a balance built partly from guesses is worse than one that says what was measured.
12-hour charting summary
What actually changed, in the order it changed
✦
Summary of 22 vitals entries across 7 beds
Draft — awaiting approval
Four of seven beds are unchanged from the 08:00 round. Three moved: GM-03 temp 102.4 → 100.6 °F and pulse 112 → 98 across five sets; SP-03 BP 96/58 at 07:55 rising to 108/66 at 10:20; GM-05 pain 4/10 → 2/10 at rest after the 08:15 Paracetamol. One value is still outstanding: GM-01's 10:00 post-dose BP has not been charted.
✦ Summarised from the 22 vitals entries recorded on this shift. Every number above appears in the charts as typed — nothing was rounded, averaged or filled in.
NEWS aggregate — from your 10:30 set
Arithmetic on six recorded values, against the published NEWS2 scale
2/ 20 possibleWas 6 at 02:00
Respiratory rate 20 /min
Scale band 12–20
SpO₂ 97% on room air
Scale band ≥ 96, no oxygen
Systolic BP 120 mmHg
Scale band 111–219
Pulse 98 /min
Scale band 91–110
Consciousness — alert
AVPU: A
Temperature 38.1 °C (100.6 °F)
Scale band 38.1–39.0
HOS adds up what you charted and names the band the published scale puts it in. It does not say what will happen next, does not assign an acuity level, and does not change the observation frequency your protocol already sets. Displaying a score computed from recorded values is not a prediction.
IV fluids & cannula sites
4 lines across my beds · VIP scored at every check
GM-03 · Mohd. Irfan90 ml left
NS 0.9% 500 ml · 150 ml/hr · hung 08:05 · 410 ml in
Empties ≈ 11:23 · next bag ready by 11:15 · cannula day 1, VIP 0
SP-01 · K. NarayanaVIP 2
Saline lock · cannula day 3 · left forearm
Redness along the vein, no pain on palpation. Ward policy resites at VIP 2.
GM-05 · B. SrinuVIP 0
Saline lock for 11:00 Ceftriaxone · cannula day 2 · right hand
Site clean and dry, dressing intact, flushes freely.
GF-01 · Lakshmi DeviVIP 0
Saline lock · cannula day 1 · left hand
For blood sampling only — repeat K due 22:00.
✦
Pre-op checks drafted — D. Prakash, TKR Monday 09:00
Draft — awaiting approval
From Reception's admission record of 10:32 today and the ward's own pre-op schedule.
Nothing has been charted — these are the items and their due times.
The last row is the one that cost the theatre ₹18,574 this morning on a different case —
OT-1's first case could not be sent for because the site was unmarked at 08:00.
HOS cannot mark a site, cannot tick a WHO checklist item, and cannot let this approval stand in
for the surgeon's. It is listed here so nobody discovers it at 08:45 on Monday.
Reassessment schedule
Due time first · 1 overdue, 2 due within the hour
1 overdue
2 due < 1 h
| Due | Status | Assessment | Patient · bed | Last done | |
|---|---|---|---|---|---|
| 08:00 | 2 h 47 m late | Braden — pressure sore, 48-hourly | G. Vijaya Lakshmi · SP-03 | 16 Jul 08:00 | |
| 11:00 | in 13 min | Wound — surgical site + dressing change | B. Srinu · GM-05 | 17 Jul 11:00 | |
| 12:00 | in 1 h 13 m | Pain score — 4-hourly while on analgesia | K. Narayana · SP-01 | 09:30 | — |
| 14:00 | Scheduled | Morse — fall risk, daily | B. Srinu · GM-05 | 17 Jul 14:00 | — |
| 16:00 | Scheduled | Braden — 48-hourly | B. Srinu · GM-05 | 16 Jul 16:00 | — |
| 20:00 | Scheduled | Catheter care bundle — 12-hourly | B. Srinu · GM-05 | 08:00 | — |
| 08:20 | Done 08:20 | Braden — 48-hourly | Lakshmi Devi · GF-01 | 18 Jul 08:20 | Score 18 — mild band |
✦Overdue reassessment reminderDraft — awaiting approval
SP-03's 48-hourly Braden reassessment passed its due time at 08:00 and is now 2 h 47 m outstanding. She is Day 5 with limited mobility, so this is the interval your own ward schedule sets — HOS is only pointing at the clock. Drafted reminder for the ward WhatsApp group, addressed to me and copied to Sister Vasavi.
✦ From the reassessment schedule above and the last recorded Braden (16 Jul 08:00). No clinical claim is made about her skin.
Braden — G. Vijaya Lakshmi · SP-03
Six subscales you score · the total is their sum, nothing else
14/ 23 · min 6
Published band: moderate (13–14)
Sensory perception
Responds to verbal commands, cannot always report discomfort
Moisture
Skin occasionally moist, linen changed once a shift
Activity
Chairfast — walks only with maximum assistance
Mobility
Very limited — slight changes only, needs help to reposition
Nutrition
Probably inadequate — eats about half of most meals
Friction & shear
Potential problem — slides in the chair, needs minimum assistance (max 3)
3 + 3 + 2 + 2 + 2 + 2 = 14. The published Braden bands are 19–23 no risk, 15–18 mild, 13–14 moderate, 10–12 high, ≤ 9 very high. HOS names the band. It does not say what her skin will do, and it does not order anything.
Wound — B. Srinu · GM-05
Right knee, midline surgical incision · dressing change due 11:00
Photo 17 Jul 11:04
encrypted store
encrypted store
Kept in the record, never in the tablet's gallery (DPDP: purpose limitation, minimisation).
Length
14 cm
unchanged
Exudate
Nil
since Day 3
Edges
Apposed
no gaping
Peri-wound
Intact
no erythema
Dressing: dry gauze + transparent film. Aseptic technique, no soakage on removal at the last change. Drain removed Day 3.
✦Wound note drafted from your observationsDraft — awaiting approval
18 Jul, 11:00 — Right knee midline surgical incision, 14 cm, edges apposed, no gaping. No exudate, peri-wound skin intact with no erythema or induration. Dressing removed with aseptic technique, no soakage. Redressed with dry gauze and transparent film. Patient reported 2/10 during the change. Next change 21 Jul or earlier if strike-through.
✦ Written from the four measurements above and the pain score you charted at 10:15. HOS does not interpret the photograph — reading a wound image would be screening, which ADR #7 puts in the RED tier and we have not enabled.
Morse fall risk — B. Srinu · GM-05
Six recorded items, summed
History of falling
None recorded this admission
Secondary diagnosis
Yes — osteoarthritis + hypertension on the chart
Ambulatory aid
Walker
IV access in situ
Saline lock, right hand
Gait
Weak — 20 m with walker at 09:40
Mental status
Oriented to own ability
0 + 15 + 15 + 20 + 10 + 0 = 60. Published Morse bands: 0–24 no risk, 25–44 low, ≥ 45 high.
Bed rails up ✓
Call bell in reach ✓
Non-slip footwear ✓
Yellow wristband ✓
Hourly rounding ×3 ✓
Those five are this hospital's own written fall-prevention bundle for the high band. HOS ticks what you documented; it does not invent an intervention.
Pain scores
Numeric 0–10 · re-scored 30–45 min after every intervention
| Time | Score | Patient · bed | Site & character | What was done | Re-score |
|---|---|---|---|---|---|
| 10:15 | 2 | B. Srinu · GM-05 | Right knee, aching, at rest (4/10 on movement) | Paracetamol 650 mg 08:15 · ice 20 min after physio | 14:00 |
| 09:30 | 5 | K. Narayana · SP-01 | Left femur, throbbing, worse on transfer | Diclofenac refused 09:04 · positioning, elevation, reassurance · Dr. P. Anil Kumar informed | 12:00 |
| 08:10 | 2 | Mohd. Irfan · GM-03 | Generalised body ache with fever | Inj. Paracetamol 1 g 06:00 (night) · tepid sponging | 14:00 |
A pain score with no re-score is the most common audit finding in Indian ward files. The re-score column is a task on the My Patients list, not a hope.
Catheter care — B. Srinu · GM-05
Foley day 4 (inserted 15 Jul, 14:20 · OT-2, during the TKR) · CAUTI bundle, 12-hourly
✓Closed drainage system intact, no disconnection since insertion
✓Bag below bladder level, off the floor, on the stand
✓Tubing secured to thigh, no dependent loops
✓Meatal hygiene with soap and water, documented 08:00
!Daily review of continued need — removal criteria met: mobilising with walker, no retention, output 720 ml overnight
✦
Removal criteria met — a catheter with no remaining indication is the single biggest driver of CAUTI
Draft — awaiting approval
Inserted 15 Jul, 14:20 in OT-2 during the TKR. 4 catheter-days recorded so far (15–18 Jul). The removal decision is the doctor's; the flag is the nurse's — HOS does not remove a catheter, it reports that the bundle's daily-review criteria are met.
Sources: catheter-care bundle, 12-hourly · nursing station device chart, GM-05.
Bundle compliance and catheter-days for the ward feed Quality & Safety → Infection Control — the same 4 days shown there, not a second count.
Estimated time saved: ~3 min this shift not spent hand-tallying catheter-days into a paper CAUTI register — these 4 days were derived automatically from the 15 Jul insertion event above. An estimate built on a per-day tallying cost, not a measured time-motion result.
Nursing care plan — B. Srinu · GM-05
Opened 15 Jul by Mary Grace · reviewed every shift · discharge planned 19 Jul
3 goals met or on track
| Status | Nursing problem | Goal (by when) | Interventions | Evaluation — 18 Jul |
|---|---|---|---|---|
| Met | Acute pain related to surgical incision |
≤ 3/10 at rest and ≤ 4/10 on movement by Day 5 | 4-hourly pain score · Paracetamol 650 mg TDS as charted · ice 20 min after physio · positioning | — |
| On track | Impaired physical mobility related to post-operative knee |
Independent transfer + 30 m with walker by discharge (19 Jul) | Physiotherapy BD · quadriceps sets hourly while awake · walker at bedside · escort for first walk each shift | — |
| On track | Risk of falls Morse 60 — high band |
No fall during this admission | Bed rails up · call bell in reach · non-slip footwear · yellow wristband · hourly rounding | — |
| Due | Risk of surgical site infection | Wound clean, dry, no erythema until suture removal Mon 27 Jul | Aseptic dressing per schedule · 4-hourly temperature · Ceftriaxone as charted · daily wound photograph | — |
| In progress | Knowledge deficit home exercises, wound care, red flags |
Patient and daughter teach-back complete before discharge | Telugu leaflet · demonstration of exercises · red-flag teaching · pharmacy counselling booked with Ravi Teja | — |
Five problems, five goals, all written by a nurse. The evaluation column is the only part HOS drafts, and only from values already in the chart.
My other six plans
Next review first — a plan nobody reviews is paperwork, not care
| Next review | Patient · bed | Primary nursing problem | Goal | Status |
|---|---|---|---|---|
| 12:00 | Lakshmi Devi · GF-01 | Risk of electrolyte imbalance related to CKD 3a | K within the range Dr. Ramesh set, by the 22:00 repeat | Read-back open |
| 13:00 | SP-03 · G. Vijaya Lakshmi | Risk of pressure injury — Braden band moderate | Skin intact over sacrum and heels through this admission | Braden overdue |
| 16:00 | Mohd. Irfan · GM-03 | Hyperthermia related to infection under investigation | Temp < 99.5 °F for 24 h before step-down of 4-hourly obs | On track |
| 16:00 | K. Narayana · SP-01 | Acute pain with a documented analgesia refusal | Acceptable pain control on an agent the patient will take | Awaiting doctor |
| 18:00 | Padma Sree · GF-03 | Risk of maternal and foetal complication — antenatal 24 w | BP and urine protein within Dr. Sunitha Rao's recorded limits | On track |
| 19:00 | Venkatesh Naidu · GM-01 | Ineffective health management — hypertension | Two consecutive charted BPs below the target in the order | BP not charted |