Plan of Care Note

A&Ox _____ (disoriented to_____). VSS on _____ (O2 source).

Telemetry (if present). CIWA (if present). Neuro checks (if
present). Denies pain (or location and intervention). Swallows
pills _______ (whole or crushed/NPO). Bathroom (Up to toilet or
BSC, assisted with bed pan, incontinent). Skin (if any interventions
performed). Restraints (if present). Lines (if applicable, any CVAD or
continuous fluids). Bed mobility (independent, T&R q2h with assist
of 1 or 2). Ambulating (independently, with Ax1 or 2 with RW).
Specialty bed or Accumax (if applicable). Bed alarm on (if
applicable). Safety maintained. Hourly rounding performed. See
flowsheet for further details.
 Patient Report Guide
Name/Age/Sex: 
Code Status:
Allergies:  (if more than 2 say "multiple allergies, see chart for details")
Chief Complaint: (also any pertinent history)
Neuro: A&Ox
Pain/CIWA/Neuro checks/Language interpreter (if applicable)
Resp: O2 Source
Cardiac: Tele/HR/BP (if applicable or abnormal)
GI/GU: Swallows pills
Diet /Fingerstick if applicable
Continent/incontinent or foley/ostomies (toilet/bedpan/commode with Ax_)
Last BM
P/V: IV's and CVADs
Any continuous infusions
Edema (If applicable)
Skin: Intact or wounds & locations
Activity: Independent/Ax1-2/RW, cane etc. *Restraints (if applicable)
Plan: ex. "IV abx" or "D/C to STR" or "Continue workup"