Daily Goal Sheet
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1Daily Goal Sheet
Pt Name______________
Date_____________
Last 4________________
Service___________
1. Pain Control
Drip________ Intermittent_________
& Sedation
PCA ________ Epidural____________
2. Vent
Trial
____Yes ___No ____Contraindicated
_______Yes
HOB at 30 degrees
____Yes ___No ____Contraindicated
_______No
Sedation vacation
____Yes ___No ____Contraindicated
PUD prophylaxis
____Yes ___No ____Contraindicated
DVT prophylaxis
____Yes ___No ____Contraindicated
Extubate
____Yes ___No
3. Medications
Reviewed: ___Home ____Daily
Start__________
Titrate_________
D/C__________
4. Blood Products
PRBC_____ FFP______ Platelets____
5. Fluid Balance
__________Liters
__________CVP/PCWP goal
6. Monitoring Devices
* Swan
Cont____ D/C____ Change____
* TLC
Cont____ D/C____ Change____
* A-Line
Cont____ D/C____ Change____
* Foley
Cont____ D/C____ Change____
7. Chest Tube
To Suction_________
To Gravity_________
To be D/C’ed_________
8. Nutrition
TPN: Same_____ Change______
TF_______ Diet_______
Calorie count______ Dentures____
9. Major Tests & Procedures
New line___________
for the Day
Diagnostic imaging_______
Other____________
10. Activity
BR_____ OOB________
Ambulate_______ Walker_______
11. Family Meeting
Needed______ Scheduled_______
12. Transfer Out
Yes_________ Location________
13. Restraints
Yes_________ No________
Orders needed: Yes______ No______
14. Consults Needed
PT/OT_______ Geriatrics_______
Social work_____ Psychiatry______
Palliative care____ Other________
15. Geriatric Issues
Glasses: Needs_____
Has_______
Hearing aids: Needs____ Has_______
Music therapy: Needs____ Has_______
Books on tape: Needs______ Has_____
Calendar: Needs____ Has_______
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Parent category: Miscellaneous