Patient Info Admitting Dx: Hx:

Name:

Room #
Activity/Ambulation: I/O + -
Age:

DOB
Cane RW WC Lift
IV Fluids: Precautions  Neutropenic
Allergies
 Aspiration  MRSA
 Bleeding  Airborne
Code Status
 Fall  Droplet
Full DNR DNI
 Seizure  ____________

Radiology Vital Signs Plan/Interventions Labs

X-Ray HR: 1.
CT Scan Resp: 2.
MRI 3.
Temp: 4.
US
BP: 5.
Other
Tubes O2 Sat: 6. RBC___Mag____PO4____
Drainage PT____INR____ PTT____
 Room Air  NC 
7. Ca_____
Catheters NRB
LPM _____
8. Cultures
Feed/NG
9.  Blood  Urine  Flu
Pain:
Cardio – EKG, Rhythm, Pulses Respiratory – IS, Sounds, SOB, Cough Musculoskeletal – Fx, Sprains, Arthritis

Skin – Color, Edema, Wounds GU – Catheter, U/A, UTI, CBI Abdominal/GI – Last BM, bowel sounds

Neuro/LOC – PERRLA, GCS HEENT - Mucosa, teeth, hearin Nutrition/Diet – liquids, Cardiac, crushed

Medications: Notes:
Patient Info Admitting Dx: Hx:
Name:

Room #
Activity/Ambulation: I/O + -
Age:

DOB
Cane RW WC Lift
IV Fluids: Precautions  Neutropenic
Allergies
 Aspiration  MRSA
 Bleeding  Airborne
Code Status
Full DNR DNI  Fall  Droplet
 Seizure  ____________

Radiology Vital Signs Priorities Labs

X-Ray HR: 1.
CT Scan Resp: 2.
MRI 3.
Temp:
US
4.
BP: 5.
Other
Tubes O2 Sat: 6. RBC___Mag____PO4____
Drainage PT____INR____ PTT____
 Room Air  NC  7. Ca_____
Catheters NRB
LPM _____ 8. Cultures
Feed/NG  Blood  Urine  Flu
Pain:
9.
Cardio – EKG, Rhythm, Pulses Respiratory – IS, Sounds, SOB, Cough Musculoskeletal – Fx, Sprains, Arthritis

Skin – Color, Edema, Wounds GU – Catheter, U/A, UTI, CBI Abdominal/GI – Last BM, bowel sounds

Neuro/LOC – PERRLA, GCS HEENT - Mucosa, teeth, hearing Nutrition/Diet – liquids, Cardiac, crushed

Medications: Notes:
Patient Info Admitting Dx: Hx:
Name:

Room #
Activity/Ambulation: I/O + -
Age:

DOB
Cane RW WC Lift
IV Fluids: Precautions  Neutropenic
Allergies
 Aspiration  MRSA
 Bleeding  Airborne
Code Status
 Fall  Droplet
Full DNR DNI
 Seizure  ____________

Radiology Vital Signs Priorities Labs

X-Ray HR: 1.
CT Scan Resp: 2.
MRI 3.
Temp:
US
4.
BP: 5.
Other
Tubes O2 Sat: 6. RBC___Mag____PO4____
Drainage PT____INR____ PTT____
 Room Air  NC  7. Ca_____
Catheters NRB
LPM _____ 8. Cultures
Feed/NG  Blood  Urine  Flu
Pain:
9.
Cardio – EKG, Rhythm, Pulses Respiratory – IS, Sounds, SOB, Cough Musculoskeletal – Fx, Sprains, Arthritis

Skin – Color, Edema, Wounds GU – Catheter, U/A, UTI, CBI Abdominal/GI – Last BM, bowel
sounds

Neuro/LOC – PERRLA, GCS HEENT - Mucosa, teeth, hearing Nutrition/Diet – liquids, Cardiac,
crushed

Medications: Notes:
Patient Info Admitting Dx: Hx:
Name:

Room #
Activity/Ambulation: I/O + -
Age:

DOB
Cane RW WC Lift
IV Fluids: Precautions  Neutropenic
Allergies
 Aspiration  MRSA
 Bleeding  Airborne
Code Status
Full DNR DNI  Fall  Droplet
 Seizure  ____________

Radiology Vital Signs Priorities Labs

X-Ray HR: 1.
CT Scan Resp: 2.
MRI 3.
Temp:
US
4.
BP: 5.
Other
Tubes O2 Sat: 6. RBC___Mag____PO4____
Drainage PT____INR____ PTT____
 Room Air  NC  7. Ca_____
Catheters NRB
LPM _____ 8. Cultures
Feed/NG  Blood  Urine  Flu
Pain:
9.
Cardio – EKG, Rhythm, Pulses Respiratory – IS, Sounds, SOB, Cough Musculoskeletal – Fx, Sprains, Arthritis

Skin – Color, Edema, Wounds GU – Catheter, U/A, UTI, CBI Abdominal/GI – Last BM, bowel
sounds

Neuro/LOC – PERRLA, GCS HEENT - Mucosa, teeth, hearing Nutrition/Diet – liquids, Cardiac,
crushed

Medications: Notes: