EHR Simulation - Nurse Training Interface

Patient Name --

MRN --

Account # --

DOB / Age --

Room / Bed ICU 301-A

Allergies

Patient Demographics

Medical Record Number (MRN) *

Account Number (Visit #) *

Admission Date

Personal Information

Last Name *

First Name *

Middle Name

Date of Birth *

Sex Assigned at Birth *

Gender Identity

Preferred Pronouns

Contact Information

Address

City

State

ZIP Code

Phone Number

Emergency Contact

Contact Name

Relationship

Phone Number

Medical Information

Allergies *

Code Status

Primary Language

Interpreter Needed?

Insurance Information

Insurance Provider

Policy Number

Group Number

Medical History

Past Medical History (PMH)

Hypertension (HTN)

Diabetes Mellitus (Type 1/2)

Coronary Artery Disease (CAD)

COPD/Asthma

Chronic Kidney Disease

Heart Failure (CHF)

Other Medical History / Details

Surgical History (PSH)

Surgeries & Procedures

Family Medical History

Cancer (Family)

Heart Disease (Family)

Diabetes (Family)

Family History Details

Social History

Occupation

Tobacco Use

Alcohol Use

Illicit Drug Use

Primary Substance

Method of Use

Frequency

Last Use

Social History Notes

Vital Signs

Account Number (Visit #)

Record New Vital Signs

Date

Time

Blood Pressure

/ mmHg

Limb

Heart Rate

bpm

Respiratory Rate

breaths/min

Temperature

°F

SpO2

O2 Delivery

Pain Scale (0-10)

Pain Location

Weight

Height

BMI (calculated)

Vital Signs History

Date/Time	BP	HR	RR	Temp	SpO2	Pain	Actions
No vital signs recorded yet

Medication Administration Record (MAR)

Account Number (Visit #)

Active Medications

Medication	Barcode ID	Dose/Route/Freq	Last Given	Next Due	Status	Actions
No medications ordered

Administration Log

Date/Time	Medication	Dose	Route	Site (if applicable)	Nurse Initials
No administrations recorded

Nursing Assessment

Assessment Date

Assessment Time

Assessment Type

Neurological

GCS: Eye Opening (E)

GCS: Verbal Response (V)

GCS: Motor Response (M)

GCS Total Score

15 Mild (Normal)

Left Pupil

Right Pupil

Motor Function

Neurological Notes

Cardiovascular

Regular Rhythm

Irregular Rhythm

Peripheral Pulses Present

Edema Present

Cap Refill < 3 sec

Cardiovascular Notes

Respiratory

Clear Lung Sounds

Crackles

Wheezes

Diminished Sounds

Labored Breathing

Productive Cough

Respiratory Notes

Gastrointestinal

Bowel Sounds

Last Bowel Movement

Diet Tolerance

Gastrointestinal Notes

Genitourinary

Urine Output (mL/hr)

Urine Color

Catheter Type

Genitourinary Notes

Integumentary (Skin)

Skin Intact

Warm & Dry

Wound Present

Pressure Injury

Rash Present

Bruising

Integumentary Notes

Musculoskeletal & Mobility

Mobility Level

Fall Risk

Full Range of Motion

Limited ROM

Steady Gait

Uses Assistive Device

Musculoskeletal Notes

Care Plans & Interventions

Active Care Plans

No care plans created yet

Communication & Handoff Tools

SBAR Report

SBAR (Situation, Background, Assessment, Recommendation) is a standardized communication tool for healthcare professionals.

S - Situation

B - Background

A - Assessment

R - Recommendation

Shift Report / Handoff Notes

Date

Shift

Oncoming Nurse

Shift Report Notes

Communication Log

Date/Time	Type	Recipient	Summary	Actions
No communications logged

✓ Data Saved

Patient Demographics

Personal Information

Contact Information

Emergency Contact

Medical Information

Insurance Information

Medical History

Past Medical History (PMH)

Surgical History (PSH)

Family Medical History

Social History

Vital Signs

Record New Vital Signs

Vital Signs History

Medication Administration Record (MAR)

Add Medication Order

Barcode Medication Administration (BCMA)

Active Medications

Administration Log

Nursing Assessment

Neurological

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Integumentary (Skin)

Musculoskeletal & Mobility

Care Plans & Interventions

New Care Plan

Goals

Interventions

Active Care Plans

Communication & Handoff Tools

SBAR Report

S - Situation

B - Background

A - Assessment

R - Recommendation

Shift Report / Handoff Notes

Communication Log

Patient Demographics

Personal Information

Contact Information

Emergency Contact

Medical Information

Insurance Information

Medical History

Past Medical History (PMH)

Surgical History (PSH)

Family Medical History

Social History

Vital Signs

Record New Vital Signs

Vital Signs History

Medication Administration Record (MAR)

Add Medication Order

Barcode Medication Administration (BCMA)

Active Medications

Administration Log

Nursing Assessment

Neurological

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Integumentary (Skin)

Musculoskeletal & Mobility

Care Plans & Interventions

New Care Plan

Goals

Interventions

Active Care Plans

Communication & Handoff Tools

SBAR Report

S - Situation

B - Background

A - Assessment

R - Recommendation

Shift Report / Handoff Notes

Communication Log

Select Patient