Rm# Age: Doctor/Consults:

Reason for Admit

Name:

Rm# Age: Doctor/Consults:

Reason for Admit

Name:

Rm# Age: Doctor/Consults:

Reason for Admit

Name:

Rm# Age: Doctor/Consults:

Reason for Admit

Name:

Past Medical History:

Diet: Accu: AC &HS Other: Code Status: I/O:

Past Medical History:

Diet: Accu: AC &HS Other: Code Status: I/O:

Past Medical History:

Diet: Accu: AC &HS Other: Code Status: I/O:

Past Medical History:

Diet: Accu: AC &HS Other: Code Status: I/O:

Activity:

VS:

Activity:

VS:

Activity:

VS:

Activity:

VS:

Resp Tx: O2

Monitor:

Wt:

Resp Tx: O2

Monitor:

Wt:

Resp Tx: O2

Monitor:

Wt:

Resp Tx: O2

Monitor:

Wt:

IVs Wound/Tube Care: NG Foley CT JP Penrose Trach

IVs Wound/Tube Care: NG Foley CT JP Penrose Trach

IVs Wound/Tube Care: NG Foley CT JP Penrose Trach

IVs Wound/Tube Care: NG Foley CT JP Penrose Trach

Meds:

Meds:

Meds:

Meds:

Allergies Report:

Allergies Report:

Allergies Report:

Allergies Report:

Labs/Diagnostics/Procedures to be done this shift

Labs/Diagnostics/Procedures to be done this shift

Labs/Diagnostics/Procedures to be done this shift

Labs/Diagnostics/Procedures to be done this shift

Room:

Name:

Room:

Name:

Room:

Name:

Room:

Name:

Abnormal and pertinent normal assessment findings: Neuro: Pulm: CV: Gi/Gu: M/S: Integ: Pain Management: PCA: Rhythm:

Abnormal and pertinent normal assessment findings: Neuro: Pulm: CV: Gi/Gu: M/S: Integ: Pain Management: PCA: Rhythm:

Abnormal and pertinent normal assessment findings: Neuro: Pulm: CV: Gi/Gu: M/S: Integ: Pain Management: PCA: Rhythm:

Abnormal and pertinent normal assessment findings: Neuro: Pulm: CV: Gi/Gu: M/S: Integ: Pain Management: PCA: Rhythm:

Vital signs: I/O:

Accucheck:

Vital signs: I/O:

Accucheck:

Vital signs: I/O:

Accucheck:

Vital signs: I/O:

Accucheck:

Critical/Priority lab/diagnostic test results

Critical/Priority lab/diagnostic test results

Critical/Priority lab/diagnostic test results

Critical/Priority lab/diagnostic test results

Other:

Other:

Other:

Other:

New Orders:

New Orders:

New Orders:

New Orders:

Patient Education this shift / needs:

Patient Education this shift / needs:

Patient Education this shift / needs:

Patient Education this shift / needs:

Discharge Plans:

Discharge Plans:

Discharge Plans:

Discharge Plans:

Shift Goals

Shift Goals

Shift Goals

Shift Goals