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  • Organizational Worksheet

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    Jennifer April
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    Pt. Initials room # Allergy Check for new Dr orders 0645 Check labs Folder in Conf room by 0645 Assessment Comments P_______ B / P__________________ R______________________ PO________ on _________ Comments Narrative note to CI Comments Time Time Diet Tube (name)_______________ Food Allergies _____________ Input and Output Foley ___ in place ______hr to be d / c Date of last

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    Pt. Initials room # Allergy Check for new Dr orders 0645 Check labs Folder in Conf room by 0645 Assessment Comments P_______ B / P__________________ R______________________ PO________ on _________ Comments Narrative note to CI Comments Time Time Diet Tube (name)_______________ Food Allergies _____________ Input and Output Foley ___ in place ______hr to be d / c Date of last

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    59 views4 pages

    Organizational Worksheet

    Uploaded by

    Jennifer April
    Pt. Initials room # Allergy Check for new Dr orders 0645 Check labs Folder in Conf room by 0645 Assessment Comments P_______ B / P__________________ R______________________ PO________ on _________ Comments Narrative note to CI Comments Time Time Diet Tube (name)_______________ Food Allergies _____________ Input and Output Foley ___ in place ______hr to be d / c Date of last

    Copyright:

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    of 4

    Pt. initials . Pt. initials .

    Room # . Room # .
    Allergy . Comments Allergy . Comments
     Check for new Dr orders  Check for new Dr orders
    0645  Check labs  Check labs
     Folder in Conf room by  Folder in Conf room by
    0645 0645

     Assessment  Assessment
    0700 T_______ B/P_____/_____ T_______ B/P_____/_____
    P______________________ P______________________
    R______________________ R______________________
    PO________ on __________ PO________ on __________

    0730

    0800

    0830

    0900
    Pt. initials ___________ Pt. initials ___________
    Room #______________ Room #______________
    Allergy_______________ Comments Allergy_______________ Comments

    0930

    1000

    1030

    1100

    1130

    1200

    1230

    1300

     Narrative note to CI  Narrative note to CI


    1330

    1400

    1430

    1500
    Assignment Sheet

    Date: Surgery: Date: Surgery:


    Pt initials: Room #: Pt initials: Room #:
    Age: Drs: Age: Drs:
    Allergies: Allergies:
    Admit Dx: Admit Dx:
    2nd Dx: 2nd Dx:

    Time Medication (Labs, supplies) Time Medication (Labs, supplies)

    Diet Activity Diet Activity


    Tube (name)______________ BR ___ BR c BRP ___ BSC ____ Tube (name)_______________ BR ___ BR c BRP ___ BSC ____
    Food Allergies ___________ Up ad lib_____ Ambulate______ Food Allergies _____________ Up ad lib____ Ambulate_____
    WBAT ____ OOB in Chair_______ WBAT ___ OOB in Chair_____
    Walker ____ Crutches _____ Walker ____ Crutches _____
    PT _________________________ PT ______________________
    BGM freq___________ _ OT_________________________ BGM freq____________ OT_______________________
    Dentures: ___Yes ____No Other_______________________ Dentures: ___Yes ____No Other_____________________
    Assessment: VS q__________ Assessment: VS q________

    Time:_____ T_______ P______R______B/P________ POx____ Time:_____ T______ P_____R_____B/P________ POx______

    Time:_____ T_______ P______R______B/P________ POx____ Time:_____ T______ P_____R_____B/P________ POx______

    Time:_____ T_______ P______R______B/P________ POx____ Time:_____ T______ P_____R_____B/P________ POx______

    Time:_____ T_______ P______R______B/P________ POx____ Time:_____ T______ P_____R_____B/P________ POx______

    Input and Output Foley ___ in place ______hr to be d/c Input and Output Foley ___ in place ______hr to be d/c
    Date of last BM: _________________ Date of last BM: _________________

    Last 24 Hr I/O: _____________ / ______________ Last 24 Hr I/O: _____________ / ______________


    IVs SPECIAL PRECAUTIONS IVs SPECIAL PRECAUTIONS
    IV Type / Fluid / Rate / Site Falls ____ Seizure ____ IV Type / Fluid / Rate / Site Falls ____ Seizure ____
    Isolation____ Isolation____
    Aspiration____ Restraint ____ Aspiration____ Restraint ____
    Iso / Hypo / Hyper -tonic fluid Isolation____ Iso / Hypo / Hyper -tonic fluid Isolation____
    Saline Lock Skin: turn Q2H________ Saline Lock Site(s)__________ Skin: turn Q2H________
    Site(s)__________
    Hemovac / Wound Care (dressing change) Hemovac / Wound Care (dressing change)

    Hygiene: ___Complete ___Assist ___Self Hygiene: ___Complete ___Assist ___Self


    Bath Shift:  7-3  3-11  11-7 Bath Shift:  7-3  3-11  11-7
    Labs Labs

    Other Other
    Assignment Sheet

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