Meds/procedures
P ain
1900
Allergies
S
2000
Admit
d ate
Code
s tatus
1
D x
Full
2
D x
DNR
C/O
DNI
2100
Language:
A ge:_____
M /F
B
History
Isolation
/ Protocols
CP
Contact
V RE/MRSA
3
Airborne
1
2200
0
Falls
R isk
R estraints
Cardiac:
Pain/sedation
A
Pain
s cale
7
Peripheral
p ulses
Location
Edema
0
2300
Meds
t ype
a nd
l ast
d ose
Heart
s ounds
2
PCA
Current
r hythm
B ase_____
VTE
p rophylaxis
( by
0 000)
-
H EP
S CD’s
CP
B olus____
4
3
BP
0000
D ose_____
1
HR
1
Pulmonary:
T x:
q ____
Accu
c hecks
9
0
Frequency
RR
7
SpO2
Last
R esults
7
0100
TEMP
Diet
0
CP
3
GI
Skin
2
CP
1
3
-
Wounds
NG/PEG
0
0200
1
4
Drainage
BS
0
1
Drains
7
Last
B M
9
Location
0
7
7
0300
Ducub
I
I I
I II
I V
U S
P hoto
D ate_____
2
0
GU
F oley/void
Psych
S ocial
CP
-
2
Output
3
4
-
1
IV
H L
P ICC/CENTRAL
( by
0 500)
Musc/Skel
1
0400
4
0
Date
i nserted________
9
1
Mobility
CP
7
3
9
Fluids
G tts
7
Na
Cl
Bun
gluc
mg
BNP
PT
H ct
UA
CT
1
7
0
0500
CP
Stool
3
CXR
0
2
PTT
K
Co
Cr
Ca
Phos
DDi
Cultures
1
WBC
P l
MRI
-
mer
INR
0
7
4
Echo
0600
Next
l abs/Procedures/Blood
H gb
0
1
ERCP
CBC
B NP
7
2
9
Consent/Attestation?
0
-
7
DC
P lan.
Shift
g oals
R
2
CP
4
VS
q _______
I /0_______
( Foley/hat)
3
0700
-
1
1
Daily
w t_____
4
9
0
1
7
9
7
7