Patient Name:
Outside Room
Situation
Room:
Attending/Service:
Physician/Ancillary
Consult
Date
Reason
Adm Date:
Isolation:
Physician/Ancillary
Consult
Date
Reason
History
Allergies:
Oncology:
Treatment:
Pertinent History:
Psychosocial History and Assessment:
Capacity: Y/N
MPOA/Surrogate:_____________________________________ Living Will: Y/N
Custody Issues/Documents:
Privacy Status:
Limitations on who can be at bedside or not have information:____________________________________________
Dynamics:
Mentation/Psych Concerns:
HI or SI: Y/N Plan:
Detox:
Discharge Plan or Placement Issues:
Neuro
A/O:
Neuro Checks:
GCS:
Deficits:
Cardiac Vitals Q_______ Telemetry:
Rate/Rythym:
T______________ HR___________________ RR_______________
B/P____________________ Sat______________
Anticoags/Education:
Musculoskeletal Activity/Order:
Assistive Devices:
PT:
Deficits:
Amputation:
Peripheral Vascular CMS Checks:
Cap Refill:
Pulses:
DVT Prevention*: SCDs
TEDS
Edema:
Meds
Safety* Name band______ Allergy______ Fall*______ DNR_____ Limb
Alert______ Latex______
Bed/Chair Alarm_______
Restraints* Order date:
Type:
Documentation:
Sitter:
1:1Video Monitoring:
Disease Specific Precautions:
Infectious Disease Isolation:
Abx:
Why:
Peak/Trough:
Culture Site/Organism:
Requirements: Daily Wt:
Blood Products:
Procedure:
Bath:
Daily Plan of Care:
Respiratory Lung Sounds:
O2:
IS:
Nebs/Meds:
CPT:
Suction:
Chest Tube:
Trach:
BiPAP/CPAP/Hi-Flow Settings:
GI/GU Bowel Sounds:
Diet:
NG/PEG:
Sx/Flush:
Colostomy:
Tube Feeds:
BM:
Foley*:
Why:
Foley Care:
Date Inserted:
Date Removed:
Urostomy:
Dialysis:
Incontinent Y/N
Intake: Shift total(PO)________(IV)______24h total(PO)______(IV)_______
Output(urine, emesis, drains): Shift total__________ 24h total__________
Integumentary Color:
Temp:
Wound(stage, location, characteristics, dressing):
Surgical Sites:
CPM/Traction/Trapeze/ Abductor:
Inside Room
Code Status:
NPO
Assessment
*Never Events
Age:
Chief Complaint/Diagnosis:
Fluid Restriction:
Due Labs/Specimens:
Consent/Checklist:
Discharge Planning:
Patient Concerns:
Events (Significant Occurrence During Hospitalization):
Pressure devices:
Specialty Bed:
Endocrine FS:
Insulin Coverage:
Oral Meds:
Diabetic Education/New Diagnosis:
LDAW IV Site:
Central Line*:
Drains:
High-Risk Meds*:
IV Tubing Date:
Drsg Date:
Access Date:
Rate Verify/Trace Lines*
AV Fist/Perm
Pain ____/10 before
____/10 after Location:
Description:
Interventions:
Meds & Last Dose:
PCA:
PCA Clear:
Labs and Diagnostics: Hgb________ WBC_________ BUN/Cr___________