Patient Care Plan Long 2
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1RM #
Name:
Age:
Admit:
MD:
Code:
DX:
PMH:
ISOLATION:
Allergies:
Critical to MD/charted
IV Site:
Labs
AM Labs
PT/INR
NA/K+
Dressing change:
H/H
Orders to flush central/hep loc line/PICC
Mg/Phos
NEURO: AAO x
Speech: C S A
Cardio: Tele:
Edema
O2
RA NC
Humidification
PUPILS: R___ mm E R B
Orders to travel w/o
Lung Sounds
Cough
L ___mm E R B
Pulses: Radial
Pedal
Facial Droop:
Coumadin/Fragmin/Heparin
Continuous Pulse OX
I/S/Acapella
Tongue: Midline Drift SWALLOW TEST
SCD’s
Hold BP Meds-
RT: HHN
TRACH
GI Diet:
NPO
GU URINE
Intake-
Skin/Wound
PPD
NPO w/Meds
FOLEY
Output-
Bladder Scan
Fluid Restrictions
U/A
C/S
Last BM:
/
PEG
24/HR
Strict I/O ’s
Stool check
DIALYSIS ORDERS/Consent
Checklist & MAR
+ B&T
Dressing
WOCN consult
VAC/JP
M/S
RU
RL
LU
LL
BKA
ACITVITY
Consults:
PT
Brace
Cane
Walker Wheelchair
PAIN
V/S
0800
1200
1600
HX
T
HR
MEDS
RR
B/P
O
2
FSBS
MD
orders
INSULIN Sliding
Prandial
Off unit
Test
Admission
D/C
Proced
ures
Legarcy Chart
IV
Med Hx
Vac
Allergy
P
Passport-
Consent-
MRI SCREEN SHEET
Pre-OP Proc McK Chart, Consent, Transfer Meds, MAR, V/S, On Call AB, H & P
BloodOrders for Type&Cross/ #unitsTransfus, Consent, Order for Pre-Med, Pearls, Chart input, F/U H&H
Chart:
CP:
EDU:
Charge:
Tech:
PM Report:
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