Room:
Name:
Age:
Code:
Allergies:
Iso:
Admitted:
Chief Complaint:
Dx:
MD/Consults:
CNA:
Procedures:
Hx:
NEURO:
A&O x ____ Confused □ Forgetful □ Agitated □
Neuro Checks Q ____ NIH ______ CIWA ______
Restraints/Sitter:
Pain:
HEENT:
Hearing Aids R/L □ Blind R/L □ Glasses □
RESP:
RA □ NC □ HF □ CPAP □ BiPAP □
____ L
CARDIAC:
Tele:
Pacemaker:
GI:
Continent □ Incontinent □ Last BM ________
Ostomy:
PEG/NG:
GU:
Continent □ Incontinent □ Oliguric □ Anuric □
BR □ Brief □ BSC □ Urinal □ Purewick □
Condom Cath □ Bedpan □ Foley □ ____________
Strict I&O □ Urinary Output: _________
MSK:
Mobility: Indep □ 1 assist □ 2 assist □ Bedrest □
Devices: FWW □ Cane □ Lift □ WC □
Orthotics/Brace/Splint:
Weight Bearing:
SKIN:
Wounds/Incisions:
Pressure Ulcer:
Protective Devices:
PV:
Edema:
VTE prophylaxis:
□F □M
LAB
T:
T:
T:
Na
K
Cl
Mg
Phos
CO2
Glucose
BUN
Creat
Anion Gap
Lactate
AST
ALT
LAB
T:
T:
T:
WBC
RBC
Hgb
Hct
Platelet
PT
INR
PTT
Trop
BNP
CK-MB
Ammonia
Vanco T
DIET
Restrictions:
Pills Whole □ Crushed □ Feeder □ Supervised □
Tube Feeds:
TPN/Lipids:
BLOOD SUGAR
AC&HS □ Q4 □ Q6 □ Q8 □
Sliding Scale □ Nutritional Dosing □
LINES/IVF/DRIPS
Access
1.
2.
3.
4.
DRAINS
JP:
Hemovac:
IVF/Drip
Dialysis: MWF □ TTS □ PD □
Access:
AccuCheks: _______, _______, _______
Chest Tube:
Water Seal □ Suction □ _______
Tidaling □ Air leak □ _______
Output:
DIAGNOSTICS/IMAGING
PLAN
DISCHARGE:
Date: _________ Time: _________ Location: _________________ Transport: _______________
VITALS
Temp
BP
HR
RR
SpO2
TIME:
TIME:
TIME: