Name: ________________ Room #: _______

Age: ____ y/o M / F Hospitalists / Trauma / CFP

Admitted: _____________ FULL CODE / DNR

S
Situation

PMH: ​ DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD / COPD / Asthma / CKD / ESRD / Smoker
B / Drug Abuse / Psych / CVA / Dementia / Hypothyroid / CA /
Tests: ​ MRI / X-Ray / CT / Echo EF: ____ / Endo / US / Cath
Background

IV:​ #_____ R / L SL ​Date:​ ___________ IVF:​ NS / ½ NS / D5 ½ / D5 NS / LR / Abx

A Site:​ AC / FA / Hand / Wrist / UA
Central:​ IJ / PICC / Port / Trialysis
IV Rate: ​_____ ml/hr / _____ u/kg/hr
Drips:​ Heparin / Blood / TPN / Dilt
Assessment
Neuro Pain
A & O x ___ / Confused Level:
Contact:
Activity:​ Up ad lib / 1 / 2 / Bed-rest Location:
MRSA
Walker / Cane Medication:
C-Diff
Neuro Checks / Restraints / Bed Alarm Frequency:
ESBL
Respiratory VS Trend
Flu
O2 @ ___L NC / Room air / NRB / CPAP / BIPAP / ​Trach:​ _______ HR Temp
Droplet
Breath Sounds:​ Clear / Diminished / Wheezing / Crackles / Coarse BP RR
Neutropenic
Treatments:​ Nebs / IS / CPT ​Cough:​ Productive / Non-productive O​2
Cardiovascular VTE Prophylaxis
Need: SB / NSR / ST / A-Fib / A-Flutter / A-Paced / V-Paced / PACs / PVCs SCDs / Foot Pumps
Urine Cx AICD / Murmur / Block Heparin / Lovenox
Resp Cx Edema: ​None /​ ​Gen / Trace / 1+ / 2+ / 3+ Coumadin / Xarelto
Flu Swab Pitting / Non-pitting R / L / Bilateral Arms / Legs Eliquis / None Needed
MRSA Swab Pulses:​ DP Radial Dopplers / +1 / +2 Needs Order
Gastrointestinal Genitourinary
Diet:​ Reg / Clear / Full / AHA / ADA / Dysphagia I II III Voiding / Foley / Incontinence / Anuria
Extras: Soft / Renal / NPO Clear / Cloudy Yellow / Amber / Bloody
Daily Weight Hypo / Active / Hyper / Nausea / Vomiting / Diarrhea BR / Urinal / Bedside Comm / Bedpan
Strict I&Os G-tube ( LWS / Gravity ) / Ostomy​ Last BM:​ _______ Dialysis: M Tu W Th F Sa Su
Fall Risk Musculoskeletal Skin ​(Wounds & Dressings)
Observation Weakness: RUE / LUE / RLE / LLE
1:1 Sitter Numbness: RUE / LUE / RLE / LLE
NPO @ Midnight
BG Monitoring AC B AC L AC D HS Labs
AC&HS / Q6​o​ / Q___​o WBC K CKMB
Drains Hgb INR BNP
Chest Tube /​ ​JP / Hemovac / Accordion / Wound Vac Na Anti-Xa Trop
( R / L ) Level: _____ Plt Cr Lipase
Serosanguinous / Sanguineous NH​3 LFTs

Scheduled Procedures: ​Cath / US / Stress / Echo / Dopplers / MRI

R Consults:​ CM / PT / OT / GI / Cards / Neuro / Nephro / Wound / Ortho / Psych / Pulm / Surg
Recommendation Discharge to: ​Home / Home Health / ALF / SNF / Rehab