Patient Care Plan Long
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1RM #
NAME:
AGE: MD:
CODE: FULL DNR DNL
ADMIT :
DX:
PMH:
Allergies:
IV SITE:
Activity:
NG
V/S
T
HR RR
B/P
O2
BR UTC Ad Lib
JP
0700
BSC BP
Total
G/J Tube
1100
assist
1600
Trach #
Dressing:
self
Hx
LABS:
AM LABS:
Isolation
D/C
Meds REC
CDIFF
Home Inst Vaccines
FSBS: Q:
HX
D/C IV
RX
MRSA
Sign chart Care plan
Critical to MD
VRE
Pearls
Speech: C S A
Cardio: Tele:
Cap Refill
Edema O
Lung Sounds
Cough
Neuro AAO x
2
MAE
RUE
RLE
ULE
LLE
Tingling
Numbness
Weakness
Pupils R:
mm
B /S/ NR/F
L:
mm B /S/ NR /F
Skin/Wound
GI
Diet:
BS:
GU URINE
Last BM:
/
VOO
FOLEY
CATH
Pain/MEDS
MEDS
FSBS
Passport
NPO
Consent
I/O’s
Pre-Op
CONSULTS: PT
OT SP Dietician
OFF UNIT
Antibx
IVPK Input
Procedures/Reports (chart in MISC notes)
1X Dose
IV SITE Change
Screen
MRI MRSA CTSCAN
X&Type
Blood FFP PLTS
Chart Amt I/O’s
F/U H/H
Wound Care
Neuro Checks
PCA PUMP
0800
1000
1200
1400
1600
1800
Stroke Packet
CHF
VTBI
PEARLS/PT ED
Bolus
Specimen
Attempts
PPD
Delivery
Drains-
Other-
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