Name Code Isolation Attending

Age Allergies Precautions Consults

Admitted VTE
Room#

Course

Present Illness

PMH: DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD / COPD / Asthma / CKD / ESRD / Smoker / Drug Abuse /
Psych / CVA / Dementia / Hypothyroid / CA /

Tests

Neuro Lines Meds/IVF Site Size Dose Rate

A&O IV
1
GCS Central
RASS HD
CAM Date 2
NIH
Neuro ✓s 3

Cardiovascular EF% Edema In In In In

Rhythm Pacemaker Int/Ext

Out Out Out Out
Rate Pacer A : V Pulses

Dysrhythmias % Paced Net Net Net Net

Respiratory Labs GU
Foley
O2 ___LPM FiO2%____ HD
NC NRB CPAP BiPAP Vent
Setting
GI
ETT Size___ Type
Diet
CT (R/L) Level ____ Desc ____
TF

Skin/Wounds Drains Pain AC AC AC HS

Plan