PATIENT’S NAME AGE: SEX: Wt.

ROOM: BED: DATE OF ADMISSION:

CHIEF COMPLAINT: OPERATION:________________________________________________________
DATE/TIME OF OR:___________________________________________________
ATTENDING PHYSICIAN ADMITTING DIAGNOSIS: ( ) OR AWARE___________________( ) OR NOTIFICATION ( ) CONSENT
( ) CP CLEARANCE ___WITH CARDIAC MONITOR ____W/O CARDIAC MONITOR
PRECAUTIONS: ( ) PRE-ANESTHESIA ASSESSMENT FORM
DATE MEDICATION ( ) OR CHECKLIST
ORDERED DRUG/DOSAGE/ROUTE/TIME DATE MEDICAL TREATMENT/PROCEDURES DIET: SPECIAL ENDORSEMENT:
ORDERED REMARKS

IV FLUID:

LABORATORY

IVF Side Drip/Blood Transfusion

XRAY/ULTRASOUND

NURSING SERVICE DEPARTMENT

KARDEX
MGH
CLOSE WATCH