You are on page 1of 2

Room: ________ Pt Initials: ________ Dx:___________________________________________ Age: ________ ______________________ VS Time: T: P: R: BP: Pain: Pulse Ox: Weight: VS Time: T: P: R: BP: Pain: Pulse

Ox: Weight: Diet: ____________ _________ Activity:

IV Type: Location: Rate: Type of fluid: Amt in bag at beg. of clinical: Amt in bag at end of clinical:

Blood Glucose

Time: BG: Blood Glucose

Time: BG:

Medication Schedule Time: Meds:

Time:

Meds:

Time:

Meds:

Time:

Meds:

I & O to Be Documented:

Neuro:

GI:

Resp:

GU:

C/V:

Skin:

NOTES Bath Linen change Oral care Dressing change