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RM #

Name:

Age:

DX:

Admit:

MD:

Code:

ISOLATION:

PMH:

Allergies:

Labs
Critical to MD/charted
AM Labs
PT/INR
NA/K+
Dressing change:
H/H
Orders to flush central/hep loc line/PICC
Mg/Phos
NEURO: AAO x
Speech: C S A
Cardio: Tele:
Edema
O2
RA NC Humidification
PUPILS: R___ mm E R B
Orders to travel w/o
Lung Sounds
Cough
L ___mm E R B
Pulses: Radial
Pedal
Facial Droop:
Coumadin/Fragmin/Heparin
Continuous Pulse OX
I/S/Acapella
Tongue: Midline Drift SWALLOW TEST SCDs
Hold BP MedsRT: HHN
TRACH
GI Diet:
NPO
GU URINE
IntakeSkin/Wound
PPD
NPO w/Meds FOLEY
OutputBladder Scan
Fluid Restrictions
U/A
C/S
Last BM:
/
PEG
24/HR
Strict I/O s
IV Site:

Stool check

DIALYSIS ORDERS/Consent
Checklist & MAR + B&T
M/S
RU RL
LU
LL
BKA
ACITVITY
PT
Brace Cane Walker Wheelchair
V/S

0800

1200

1600

HX

PAIN

T
HR

MEDS

RR
B/P
O2
FSBS
INSULIN Sliding

Prandial

Off unit
Admission
Legarcy Chart
Med Hx
Allergy

Dressing
Consults:

MD
orders

WOCN consult

Test
Proced
ures

D/C
IV
Vac

PassportConsentPre-OP Proc McK Chart, Consent, Transfer Meds, MAR, V/S, On Call AB, H & P

MRI SCREEN SHEET

BloodOrders for Type&Cross/ #unitsTransfus, Consent, Order for Pre-Med, Pearls, Chart input, F/U H&H
Chart:

CP:

VAC/JP

EDU:

Charge:

Tech:

PM Report:

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