RM #

NAME:

ADMIT :

DX:

AG
E:

Activity:
BR UTC Ad
Lib
BSC BP
Total
assist
self

Dressing:
AM LABS:

Speech: C S

Neuro AAO x

A
MAE RUE
RLE
ULE
Tingling
Numbness
Weakness
Pupils R:
mm B /S/ NR/F L:
B /S/ NR /F
Skin/Wound

JP

0700

G/J Tube

1100

Trach #

1600

Cardio:
Edema

D/C

Meds REC
Home Inst
Vaccines
D/C IV
RX
Sign chart Care
plan
Pearls

Tele:

HR

RR

B/P

O2

Hx

FSBS: Q:
HX

Cap Refill

O2 Lung Sounds
Cough

mm
Diet:

Last BM:
MEDS

OT SP

V/S

LLE

GI

Pain/MEDS

NG

Isolation
CDIFF
MRSA
VRE

Critical to MD

CONSULTS: PT
Dietician

CODE: FULL DNR

DNL
Allergies:

PMH:

IV SITE:

LABS:

MD:

OFF UNIT

BS:
/

GU URINE
VOO
CATH

FSBS

FOLEY

Passport

NPO

Consent

I/Os

Pre-Op

Procedures/Reports (chart in MISC notes)

Antibx
Input
1X Dose
Screen
CTSCAN

PCA
PUMP

VTBI
Bolus
Attemp
ts
Deliver
y

0800

1000

1200

1400

1600

1800

IVPK
IV SITE Change

MRI MRSA

X&Type
Blood FFP
PLTS
Chart Amt I/Os
F/U
H/H
Wound Care
Neuro Checks
Stroke Packet
PEARLS/PT ED
Specimen
PPD
DrainsOther-

CHF