patient information admitting dx/history of present illness

room #: admit date:

name:
age:
gender: isolation precautions
none contact airborne none fall aspiration
code: full dnr/dni

seizure suicide
md: safety droplet reverse

constant observation r/o or confirmed: other:

weight: lb / kg
for:
allergies past medical + surgical history
restraints
type(s):

date/time:

neuro Respiratory cardiac musculoskeletal

a &o x room air / nc l o2 telemetry moves all extremities

confused agitated pacemaker independent / bedrest / oob to chair

bipap / cpap / hfnc
forgetful. sundowns

edema: +

nrb / tracheostomy oob with assist(s)

neuro checks q h rhythm:

lung sounds: assistive device type:

nihss q h
other: other: other:
other:

gastrointestinal genitourinary integumentary intake output

diet: incontinent / continent clean/dry/intact

tube feeds / tpn / lipids : pressure ulcer(s)

bathroom / bedpan / urinal
present on arrival? YES / NO
purewick / condom catheter
accuchecks: achs / q h commode / other:
peg foley catheter
ngt l / r nare @ size/DOI:
surgical incision(s)
strict i&o's frequency: labs
fluid restriction:
gu symptoms/other:
lbm:
continent / incontinent dressings/wound care

lines/drains
bathroom / bedpan / commode peripheral iv
fms / colostomy / ileostomy

other: other skin issues

other lines/drains
gi symptoms/other: med times
0700 / 1900
0800 / 2000
dialysis catheter m/w/f t/th/s 0900 / 2100
location/type: 1000 / 2200
iv fluids/iv meds/drips/pca plan of care + notes 1100 / 2300
1200 / 0000
1300 / 0100
1400 / 0200
1500 / 0300
1600 / 0400
1700 / 0500
1800 / 0600