DATE, TIME
DIAGNOSIS :
COMPLAINT AT PRESENT:
GCS/ SENSORIUM:
VITALS: BP-, PR-, TEMP-, CBG-, I/O-, SPO2- with & without o2
CHESTCVSABDCNSANY DRESSING/WOUND/PRESSURE SORE:
CENTRAL LINE (including dialysis line)- site & date of procedure
URETHRAL CATHETER- date
Ryles tube/Drain – amount in ml
Abnormal investigations including Blood, urine, cultures,USG, CT SCAN, etc
Due reports/Last sent investigation reports
Investigations sent today
On,
Antimicrobials (day)
Any important medications like steroids, remdesevir , electrolyte correction
ADVISE:
SIGNATURE, DATE, TIME, FULL NAME, REG NO