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  • Patient Care Documentation Form

    Uploaded by

    Jan Marcus
    1K views1 page
    The document contains medical information for 3 patients including diagnoses, isolation status, codes, ECG results, fall levels, allergies, oxygen levels, levels of consciousness, activities, IV sites and fluids and rates, diets, blood glucose levels, gastrointestinal and genitourinary information, lab results, medications, PRN medications, consults, tests, surgeries and notes. Physician signatures are included at the bottom.

    Original Description:

    wound care med surg brain sheet

    Original Title

    3pt med surg nsg brain sheet

    Copyright

    © Attribution Non-Commercial (BY-NC)

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    The document contains medical information for 3 patients including diagnoses, isolation status, codes, ECG results, fall levels, allergies, oxygen levels, levels of consciousness, activities, IV sites and fluids and rates, diets, blood glucose levels, gastrointestinal and genitourinary information, lab results, medications, PRN medications, consults, tests, surgeries and notes. Physician signatures are included at the bottom.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    1K views1 page

    Patient Care Documentation Form

    Uploaded by

    Jan Marcus
    The document contains medical information for 3 patients including diagnoses, isolation status, codes, ECG results, fall levels, allergies, oxygen levels, levels of consciousness, activities, IV sites and fluids and rates, diets, blood glucose levels, gastrointestinal and genitourinary information, lab results, medications, PRN medications, consults, tests, surgeries and notes. Physician signatures are included at the bottom.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Dx:

    Isolation:

    Dx:

    Isolation:

    Dx:

    Isolation:

    Code:

    Box #:

    ECG:

    Fall Level:

    Code:

    Box #:

    ECG:

    Fall Level:

    Code:

    Box #:

    ECG:

    Fall Level:

    Allergy:

    O2:

    LOC:

    Activity:

    Allergy:

    O2:

    LOC:

    Activity:

    Allergy:

    O2:

    LOC:

    Activity:

    IV Site:

    IVF:

    Rate:

    IV Site:

    IVF:

    Rate:

    IV Site:

    IVF:

    Diet:

    AccuChek:

    GU:

    Diet:

    AccuChek:

    GU:

    Diet:

    AccuChek:

    GI:

    GI:

    Labs:

    Labs:

    Labs:

    Hgb

    HCO3

    BUN

    Cr

    Ca Mg
    P

    Whole / Crushed / AS / Peg / Thick Liq / NPO x Meds

    Hgb
    Hct

    Meds:

    Na

    Cl

    HCO3

    BUN

    Cr

    Ca Mg
    P

    Whole / Crushed / AS / Peg / Thick Liq / NPO x Meds

    Hgb

    PLT

    Meds:

    Cl

    PLT

    PLT
    Hct

    Na

    WBC

    Skin

    WBC

    Skin

    WBC

    Skin

    Hct

    Meds:

    Rate:
    GI:

    Na

    Cl

    HCO3

    BUN

    Cr

    GU:

    Ca Mg
    P

    Whole / Crushed / AS / Peg / Thick Liq / NPO x Meds

    PRN Med / Dose / Route / Frequency / Last Admin

    PRN Med / Dose / Route / Frequency / Last Admin

    PRN Med / Dose / Route / Frequency / Last Admin

    Consults / Tests / Surgeries

    Consults / Tests / Surgeries

    Consults / Tests / Surgeries

    Notes:

    Notes:

    Notes:

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    MD:

    MD:

    MD:

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