ROOM PATIENT: M F

I/O MEDICATIONS
AGE: CODE STATUS: FULL DNR
0700

ATTENDING: ADMIT DATE:

0800
ADMIT DIAGNOSIS:
0900
ALLERGIES:

PAST MEDICAL HX: 1000

1100
LINES:

1200
NEURO
AO x _____ Assist:
1300
Fall risk:: Restraits? Y N

RESPIRATORY 1400
RA O2 @ _______ L
Lung sounds: 1500

CARDIO ___ Telemetry 1600

Rhythm: Drips:

___ Foley ___ NGT 1700

GI/GU
Diet: NPO regular other: ____________
1800
Voiding: __________ Last BM: __________

SKIN ___________ drains __________ tubes 1900

pressure ulcers edema
ROOM PATIENT: M F
I/O MEDICATIONS
AGE: CODE STATUS: FULL DNR
1900

ATTENDING: ADMIT DATE:

2000
ADMIT DIAGNOSIS:
2100
ALLERGIES:

PAST MEDICAL HX: 2200

2300
LINES:

0000
NEURO
AO x _____ Assist:
0100
Fall risk:: Restraits? Y N

RESPIRATORY 0200
RA O2 @ _______ L
Lung sounds: 0300

CARDIO ___ Telemetry 0400

Rhythm: Drips:

___ Foley ___ NGT 0500

GI/GU
Diet: NPO regular other: ____________
0600
Voiding: __________ Last BM: __________

SKIN ___________ drains __________ tubes 0700

pressure ulcers edema