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Copyright 2008 GogaJET, Inc.

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PATIENT
INFORMATION
DISPOSAL
DISCLAIMER
In accordance with current HIPAA laws, please dispose of all patient
information appropriately. HIPAA protects all individually identifiable
health information which includes all information pertaining to the
patients diagnosis, treatment, as well as any patient identifiers. Be sure
to utilize your facilitys approved patient data disposal systems.
Copyright 2008 GogaJET, Inc.

Copyright 2008 GogaJET, Inc.

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Copyright 2008 GogaJET, Inc.

8:00
Med Time(s) _________________

10:00
_________________

14:00
_________________

16:00
_________________

Alexandra
J. Jefferson
2
2046
_______________________________
Name / Room
/ Bed:

Crohns Disease, DM, BKA Left Leg

HX:____________________________________________________________

07/09/10
Admit:__________________________

_______________________________________________________________

Female
54
Age:___________
Sex:_____________

_______________________________________________________________

Chemo
Colon CA
Rivero / GI - 305-321-2525
MD/Service:_____________________________
Dx:______________
Admit Reason:______________________________
AC / HS
Accucheck:_____________
BKA, Walker
Activity:__________________________
Daily Weight:________________________
AS Tolerated
Fall Precautions
Regular
Diet:__________________

Foley

Isolation: ( contact - droplets - respiratory )

Vitals
EXAMPLE

NSR / 2951
PIV - 20 Gauge - R. hand NS @ 100 ml / hr
Rhythm/Tele#:_______________________________________
IV/Date:________________________________________
NKA
Allergies:___________________________________________________________________________________________
0
______
BP:_________
Temp:_______
08:10
65 Resp:______
20
123 / 75 HR:______
Time
98.5 Pain:_______

Drips:_______________________

12:00
5
______
BP:_________
Resp:______
Temp:_______
67
20
153 / 76 HR:______
Time
98.2 Pain:_______
2
16:07 BP:_________
______
Resp:______
Temp:_______
80
20
125 / 75 HR:______
Time
96.5 Pain:_______

Drips:_______________________

O2 Sat:________
PT

91
Glucose

Drips:_______________________

Vent:______________________________________________________________________

INR

PTT

Mag

H1N1, Influenza
Vaccines:____________________________________________________

139
Na

109
CI

24
BUN

Notes:_________________________________________________________
- CT Scan Complete

3.6
K

39 2
CO

1.1
Creatinine

- Consent for PRBC

______________________________________________________________

WBC
10.6
Copyright 2008 GogaJET, Inc.

Hbg
1 1.2
HCT
33.0

- PRBC
______________________________________________________________
- MD Called @ 1400 for temp of 101.0

______________________________________________________________
Plt
236

______________________________________________________________
______________________________________________________________

BC
CT Scan

CXray

_ _
_ _
_ _

infiltrates
____________
07/09/10

Echo

_ _

__

EEG

_ _

EKG

_ _

MRI

_ _

__

__

__

U/S

_ _

X-Ray

_ _

______

_ _
_

__

_ _

__

U C/S

__

_ _
_

__

UA

__

____________
____________

ASSESSMENT
Neuro:
AA0X3

Paralysis

Confused
Pain

Respiratory:

Wheezes
Stridor
Chest Tube

Crackles
Trach
Cough

Disoriented
Ambulation

PERRLA
Gait

Rhonchi
02

Rales
IS
Non/Productive 02 - NC - 2 L

Cardio:
Pulses
HR
Rhythm & Character
Vascular Access Devices

S3
S4
Edema
Apical
Capillary Refill + 2 Edema BLE

EXAMPLE
_

__

__

__

__

__
__

X2
07/09/10
____________
____________

__

__

Done Pending

__

Copyright 2008 GogaJET, Inc.

PROCEDURES

____________

____________
____________
____________

____________
____________
____________

Notes:___________________________________________

GI:
Soft

NG Tube
Colostomy

Voiding
Miami Pouch
Foley

Intergumentary:
Edema
Turgor
Friction
Rashes

Consults:

________________________________________________

Cardiac

________________________________________________
________________________________________________

BM
Flatus
Tube Feeding

TURP
Incontinent
Character

Bladder Distened
Nephrostomy Tube
CBI

+ BS
Ileostomy

GU:

________________________________________________
________________________________________________

Distended
N/V
Incontinent

Neuro

GU
Derm
Oncology
Pain
Social Work

drsg
Clammy
TEDS
Stage I
ENT

Pulmonary

GYO
Surgery
Speech
Wound Care

Incision
Dry
SCD
Stage II

Optometry
GI
Nephrology
Anesthesia
Ortho
RadOnc

Temp
Intact
Lesions
Stage III
Endocrine
Colorectal
ID
Plastics
Spine
Psych

Med Time(s) _________________

_________________

_________________

_________________

_______________________________
Name / Room / Bed:

HX:____________________________________________________________

Admit:__________________________

_______________________________________________________________

Age:___________ Sex:_____________

_______________________________________________________________

MD/Service:_____________________________ Dx:______________ Admit Reason:______________________________

Accucheck:_____________

Activity:__________________________

Daily Weight:________________________

Diet:__________________

Fall Precautions

Isolation: ( contact - droplets - respiratory )

Foley

Rhythm/Tele#:_______________________________________ IV/Date:________________________________________
Allergies:___________________________________________________________________________________________

Vitals

______
BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
Time

Drips:_______________________

______
BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
Time
______
BP:_________ HR:______ Resp:______ Temp:_______ Pain:_______
Time

Drips:_______________________

O2 Sat:________
PT
Glucose

Drips:_______________________

Vent:______________________________________________________________________

INR

PTT

Mag

Vaccines:____________________________________________________

Na

CI

BUN

Notes:_________________________________________________________

CO 2

Creatinine

______________________________________________________________
______________________________________________________________
______________________________________________________________

Hbg
WBC

Plt
HCT

Copyright 2008 GogaJET, Inc.

______________________________________________________________
______________________________________________________________

__

__

__

__

__

_ _

MRI

_ _

UA

_ _

U C/S

_ _

U/S

_ _

X-Ray

_ _

______

_ _
_

__

EKG

_ _

__

EEG

_ _

Echo

_ _

__
__

CXray

__

_ _

__

CT Scan

__

BC

_ _
_

__

Done Pending

__

Copyright 2008 GogaJET, Inc.

PROCEDURES

ASSESSMENT
Neuro:

____________

AA0X3
Paralysis

____________

Respiratory:

____________
____________
____________
____________
____________
____________
____________
____________
____________
____________

Notes:___________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________

Wheezes
Stridor
Chest Tube

Confused
Pain

Disoriented
Ambulation

PERRLA
Gait

Crackles
Trach
Cough

Rhonchi
02
Non/Productive

Rales
IS

S3
Apical
Capillary Refill

S4
Edema

Distended
N/V
Incontinent

BM
Flatus
Tube Feeding

+ BS
Ileostomy

TURP
Incontinent
Character

Bladder Distened
Nephrostomy Tube
CBI

drsg
Clammy
TEDS
Stage I

Incision
Dry
SCD
Stage II

Temp
Intact
Lesions
Stage III

ENT
Pulmonary
GYO
Surgery
Speech
Wound Care

Optometry
GI
Nephrology
Anesthesia
Ortho
RadOnc

Endocrine
Colorectal
ID
Plastics
Spine
Psych

Cardio:
Pulses
HR
Rhythm & Character
Vascular Access Devices

GI:
Soft
NG Tube
Colostomy

GU:
Voiding
Miami Pouch
Foley

Intergumentary:
Edema
Turgor
Friction
Rashes

Consults:

Neuro
Cardiac
GU
Derm
Oncology
Pain
Social Work

LAB VALUES
Sodium (Na+)

135 - 145 mmol / L

WBC

3.5 - 9.6 mm3

Potassium (K+)
_
Chloride (CI )

3.5 - 5.2 mmol / L

RBC

3.8 - 5.2 M / uL

95 - 110 mmol / L

HGB

11.8 - 15.4 gm / dL

Carbon dioxide (C02)

19 - 34 mmol / L

HCT

34.7 - 45.2 %

Anion Gap

6 - 22 mg / dL

MCV

81.0 - 97.0 f l

Glucose

70 - 110 mg / dL

MCH

26.0 - 34.0 pg

BUN

6 - 22 mg / dL

MCHC

28.0 - 37.0 gm / dL

Creatinine

0.6 - 1.3 mg / dL

RDW

11.5 - 15.0 %

Glomer Filt Rat

>60 ml / min

Platelets

147 - 354 mm3

TBIL

0.1 - 1.1 mg / d

Neutrophil %

36 - 66 %

AST

10 - 40 U / L

Lymphocyte %

23.0 - 43.0 %

Total Protein

5.5 - 8.7 g / dL

Monocyte %

0.0 - 10.0 %

Albumin

3.2 - 5.0 g / dL

Eosinophil %

0.0 - 5.0 %

Calcium (Ca+)

8.7 - 10.5 mg / dL

Basophil %

0.0 - 1.0 %

ALT (SGPT)

7 - 55 U / L

Copyright 2008 GogaJET, Inc.

Copyright 2008 GogaJET, Inc.

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