Date.

/ /

Patient Name Age Sex Code Ward Emergency contact Care provider
Identification M/F Full Limited

Reason for Medical

S Hospitalization History
DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD
IV:# R /L SL PMH COPD / ASTHMA / CKD / ESRD / SMOKER / DRUG ABUSE
Site: AC / FA / HAND / WRIST /Ua
CBC / BMP / CMP / ECG or EKG / EEG / CT / MRI / PET / US or
B IVF: Ns /1/2 NS D5 1/2 D5 NS /LR /ABX TEST sonogram / XR or radiograph / BGT / HbA1c/ TFT / UA / PT / aPTT
IV RATE: ml/hr / u/kg/hr
LABS CBC CMP TSH PT Cl Fe
DRIPS: Heparin / Blood / Tpn / Dilt
Central: IJ / PICC PORT / TRIALYSIS VALUES BMP LP HbA1c Na Mg Ca

Medications GENITOURINARY Vital signs

09 AM/PM 08 AM/PM 12 AM/PM
1.
Voiding / Foley / Incontinence / Anuria Temperature:
2. Clear / Cloudy / Yellow / Amber / Bloody Blood Pressure:
3. Respiratory Rate:
BR / Urinal / Bedside Comm / Bedpan Heart Rate:
4. Dialysis: M Tu W Th F Sa Su Oxygen saturation:
NEURO RESPIRATORY MUSCULOSKELETAL SKIN
A Neuro Status: Alert /Oriented / confused/ SpO2 L NC / Room air / NBR / CPAP / BIPAP
Weakness : RUE / LUE / RLE / LLE
→
Intact : Y / N Location :
Site: AC /FA /HAND /WRIST /UA Trach: Wound
Activity: Up and lib / Bed -rest / Walker / Cane / Breath Sounds: Clear / Diminished / Wheezing Size :
Others: Neuro Checks / Restraints / Bed Alarm Treatments: Nebs /IS /CPT Numbness : RUE / LUE / RLE / LLE Location :
Cough: Productive / Non-productive Dressing change :
DRAINS CARDIOVASCULAR GASTROINTESTINAL SCDs Lovenox
Type : Chest Tube / JP / Hemovac / Accordion SB / NSR /ST /A-FIB / A-Flutter / A-Paced / PVCs Diet : Reg / Clear / Full / AHA / ADA Foot Pumps Comadin
Wound Vac AICD / Murmur / Block / Dysphagia / Renal/ NPO Arixtra Heparin
Edema: None / Gen / Trace / 1+ / 2+ /3+ Bowel Activity : Hypo / Active / None Needed
( R / L ) Level :
Pitting / Non-pitting R / L / Bilateral Arms / legs Hyper / Nausea/ Others
Serosanguinous / Sanguineous
Pulses: DP Radial Dopplers / 1+ / 2 Last BM:
Consults Discharge to Notes
R CM / PT / OT / GI / Cards / Neuro
Home / Home Health / ALF / SNF
Nephro / Wound / Ortho / Psych / Surg
 Date. / /

Patient Name Age Sex Code Ward Emergency contact Care provider
Identification M/F Full Limited

Reason for Medical

S Hospitalization History
DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD
IV:# R /L SL PMH COPD / ASTHMA / CKD / ESRD / SMOKER / DRUG ABUSE
Site: AC / FA / HAND / WRIST /Ua
CBC / BMP / CMP / ECG or EKG / EEG / CT / MRI / PET / US or
B IVF: Ns /1/2 NS D5 1/2 D5 NS /LR /ABX TEST sonogram / XR or radiograph / BGT / HbA1c/ TFT / UA / PT / aPTT
IV RATE: ml/hr / u/kg/hr
LABS CBC CMP TSH PT Cl Fe
DRIPS: Heparin / Blood / Tpn / Dilt
Central: IJ / PICC PORT / TRIALYSIS VALUES BMP LP HbA1c Na Mg Ca

Medications GENITOURINARY Vital signs

09 AM/PM 08 AM/PM 12 AM/PM
1.
Voiding / Foley / Incontinence / Anuria Temperature:
2. Clear / Cloudy / Yellow / Amber / Bloody Blood Pressure:
3. Respiratory Rate:
BR / Urinal / Bedside Comm / Bedpan Heart Rate:
4. Dialysis: M Tu W Th F Sa Su Oxygen saturation:
NEURO RESPIRATORY MUSCULOSKELETAL SKIN
A Neuro Status: Alert /Oriented / confused/ SpO2 L NC / Room air / NBR / CPAP / BIPAP
Weakness : RUE / LUE / RLE / LLE
→
Intact : Y / N Location :
Site: AC /FA /HAND /WRIST /UA Trach: Wound
Activity: Up and lib / Bed -rest / Walker / Cane / Breath Sounds: Clear / Diminished / Wheezing Size :
Others: Neuro Checks / Restraints / Bed Alarm Treatments: Nebs /IS /CPT Numbness : RUE / LUE / RLE / LLE Location :
Cough: Productive / Non-productive Dressing change :
DRAINS CARDIOVASCULAR GASTROINTESTINAL SCDs Lovenox
Type : Chest Tube / JP / Hemovac / Accordion SB / NSR /ST /A-FIB / A-Flutter / A-Paced / PVCs Diet : Reg / Clear / Full / AHA / ADA Foot Pumps Comadin
Wound Vac AICD / Murmur / Block / Dysphagia / Renal/ NPO Arixtra Heparin
Edema: None / Gen / Trace / 1+ / 2+ /3+ Bowel Activity : Hypo / Active / None Needed
( R / L ) Level :
Pitting / Non-pitting R / L / Bilateral Arms / legs Hyper / Nausea/ Others
Serosanguinous / Sanguineous
Pulses: DP Radial Dopplers / 1+ / 2 Last BM:
Consults Discharge to Notes
R CM / PT / OT / GI / Cards / Neuro
Home / Home Health / ALF / SNF
Nephro / Wound / Ortho / Psych / Surg
 Date.
Patient Name Age Sex Code Ward Emergency contact Care provider
Identification M/F Full Limited

Reason for Medical

S Hospitalization History
DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD
IV:# R /L SL PMH COPD / ASTHMA / CKD / ESRD / SMOKER / DRUG ABUSE
Site: AC / FA / HAND / WRIST /Ua
CBC / BMP / CMP / ECG or EKG / EEG / CT / MRI / PET / US or
B IVF: Ns /1/2 NS D5 1/2 D5 NS /LR /ABX TEST sonogram / XR or radiograph / BGT / HbA1c/ TFT / UA / PT / aPTT
IV RATE: ml/hr / u/kg/hr
LABS CBC CMP TSH PT Cl Fe
DRIPS: Heparin / Blood / Tpn / Dilt
Central: IJ / PICC PORT / TRIALYSIS VALUES BMP LP HbA1c Na Mg Ca

Medications GENITOURINARY Vital signs

09 AM/PM 08 AM/PM 12 AM/PM
1.
Voiding / Foley / Incontinence / Anuria Temperature:
2. Clear / Cloudy / Yellow / Amber / Bloody Blood Pressure:
3. Respiratory Rate:
BR / Urinal / Bedside Comm / Bedpan Heart Rate:
4. Dialysis: M Tu W Th F Sa Su Oxygen saturation:
NEURO RESPIRATORY MUSCULOSKELETAL SKIN
A Neuro Status: Alert /Oriented / confused/ SpO2 L NC / Room air / NBR / CPAP / BIPAP
Weakness : RUE / LUE / RLE / LLE
→
Intact : Y / N Location :
Site: AC /FA /HAND /WRIST /UA Trach: Wound
Activity: Up and lib / Bed -rest / Walker / Cane / Breath Sounds: Clear / Diminished / Wheezing Size :
Others: Neuro Checks / Restraints / Bed Alarm Treatments: Nebs /IS /CPT Numbness : RUE / LUE / RLE / LLE Location :
Cough: Productive / Non-productive Dressing change :
DRAINS CARDIOVASCULAR GASTROINTESTINAL SCDs Lovenox
Type : Chest Tube / JP / Hemovac / Accordion SB / NSR /ST /A-FIB / A-Flutter / A-Paced / PVCs Diet : Reg / Clear / Full / AHA / ADA Foot Pumps Comadin
Wound Vac AICD / Murmur / Block / Dysphagia / Renal/ NPO Arixtra Heparin
Edema: None / Gen / Trace / 1+ / 2+ /3+ Bowel Activity : Hypo / Active / None Needed
( R / L ) Level :
Pitting / Non-pitting R / L / Bilateral Arms / legs Hyper / Nausea/ Others
Serosanguinous / Sanguineous
Pulses: DP Radial Dopplers / 1+ / 2 Last BM:
Consults Discharge to Notes
R CM / PT / OT / GI / Cards / Neuro
Home / Home Health / ALF / SNF
Nephro / Wound / Ortho / Psych / Surg
 Date. / /

Patient Name Age Sex Code Ward Emergency contact Care provider
Identification M/F Full Limited

Reason for Medical

S Hospitalization History
DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD
IV:# R /L SL PMH COPD / ASTHMA / CKD / ESRD / SMOKER / DRUG ABUSE
Site: AC / FA / HAND / WRIST /Ua
CBC / BMP / CMP / ECG or EKG / EEG / CT / MRI / PET / US or
B IVF: Ns /1/2 NS D5 1/2 D5 NS /LR /ABX TEST sonogram / XR or radiograph / BGT / HbA1c/ TFT / UA / PT / aPTT
IV RATE: ml/hr / u/kg/hr
LABS CBC CMP TSH PT Cl Fe
DRIPS: Heparin / Blood / Tpn / Dilt
Central: IJ / PICC PORT / TRIALYSIS VALUES BMP LP HbA1c Na Mg Ca

Medications GENITOURINARY Vital signs

09 AM/PM 08 AM/PM 12 AM/PM
1.
Voiding / Foley / Incontinence / Anuria Temperature:
2. Clear / Cloudy / Yellow / Amber / Bloody Blood Pressure:
3. Respiratory Rate:
BR / Urinal / Bedside Comm / Bedpan Heart Rate:
4. Dialysis: M Tu W Th F Sa Su Oxygen saturation:
NEURO RESPIRATORY MUSCULOSKELETAL SKIN
A Neuro Status: Alert /Oriented / confused/ SpO2 L NC / Room air / NBR / CPAP / BIPAP
Weakness : RUE / LUE / RLE / LLE
→
Intact : Y / N Location :
Site: AC /FA /HAND /WRIST /UA Trach: Wound
Activity: Up and lib / Bed -rest / Walker / Cane / Breath Sounds: Clear / Diminished / Wheezing Size :
Others: Neuro Checks / Restraints / Bed Alarm Treatments: Nebs /IS /CPT Numbness : RUE / LUE / RLE / LLE Location :
Cough: Productive / Non-productive Dressing change :
DRAINS CARDIOVASCULAR GASTROINTESTINAL SCDs Lovenox
Type : Chest Tube / JP / Hemovac / Accordion SB / NSR /ST /A-FIB / A-Flutter / A-Paced / PVCs Diet : Reg / Clear / Full / AHA / ADA Foot Pumps Comadin
Wound Vac AICD / Murmur / Block / Dysphagia / Renal/ NPO Arixtra Heparin
Edema: None / Gen / Trace / 1+ / 2+ /3+ Bowel Activity : Hypo / Active / None Needed
( R / L ) Level :
Pitting / Non-pitting R / L / Bilateral Arms / legs Hyper / Nausea/ Others
Serosanguinous / Sanguineous
Pulses: DP Radial Dopplers / 1+ / 2 Last BM:
Consults Discharge to Notes
R CM / PT / OT / GI / Cards / Neuro
Home / Home Health / ALF / SNF
Nephro / Wound / Ortho / Psych / Surg
 Date. / /

Patient Name Age Sex Code Ward Emergency contact Care provider
Identification M/F Full Limited

Reason for Medical

S Hospitalization History
DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD
IV:# R /L SL PMH COPD / ASTHMA / CKD / ESRD / SMOKER / DRUG ABUSE
Site: AC / FA / HAND / WRIST /Ua
CBC / BMP / CMP / ECG or EKG / EEG / CT / MRI / PET / US or
B IVF: Ns /1/2 NS D5 1/2 D5 NS /LR /ABX TEST sonogram / XR or radiograph / BGT / HbA1c/ TFT / UA / PT / aPTT
IV RATE: ml/hr / u/kg/hr
LABS CBC CMP TSH PT Cl Fe
DRIPS: Heparin / Blood / Tpn / Dilt
Central: IJ / PICC PORT / TRIALYSIS VALUES BMP LP HbA1c Na Mg Ca

Medications GENITOURINARY Vital signs

09 AM/PM 08 AM/PM 12 AM/PM
1.
Voiding / Foley / Incontinence / Anuria Temperature:
2. Clear / Cloudy / Yellow / Amber / Bloody Blood Pressure:
3. Respiratory Rate:
BR / Urinal / Bedside Comm / Bedpan Heart Rate:
4. Dialysis: M Tu W Th F Sa Su Oxygen saturation:
NEURO RESPIRATORY MUSCULOSKELETAL SKIN
A Neuro Status: Alert /Oriented / confused/ SpO2 L NC / Room air / NBR / CPAP / BIPAP
Weakness : RUE / LUE / RLE / LLE
→
Intact : Y / N Location :
Site: AC /FA /HAND /WRIST /UA Trach: Wound
Activity: Up and lib / Bed -rest / Walker / Cane / Breath Sounds: Clear / Diminished / Wheezing Size :
Others: Neuro Checks / Restraints / Bed Alarm Treatments: Nebs /IS /CPT Numbness : RUE / LUE / RLE / LLE Location :
Cough: Productive / Non-productive Dressing change :
DRAINS CARDIOVASCULAR GASTROINTESTINAL SCDs Lovenox
Type : Chest Tube / JP / Hemovac / Accordion SB / NSR /ST /A-FIB / A-Flutter / A-Paced / PVCs Diet : Reg / Clear / Full / AHA / ADA Foot Pumps Comadin
Wound Vac AICD / Murmur / Block / Dysphagia / Renal/ NPO Arixtra Heparin
Edema: None / Gen / Trace / 1+ / 2+ /3+ Bowel Activity : Hypo / Active / None Needed
( R / L ) Level :
Pitting / Non-pitting R / L / Bilateral Arms / legs Hyper / Nausea/ Others
Serosanguinous / Sanguineous
Pulses: DP Radial Dopplers / 1+ / 2 Last BM:
Consults Discharge to Notes
R CM / PT / OT / GI / Cards / Neuro
Home / Home Health / ALF / SNF
Nephro / Wound / Ortho / Psych / Surg
 Date. / /

Patient Name Age Sex Code Ward Emergency contact Care provider
Identification M/F Full Limited

Reason for Medical

S Hospitalization History
DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD
IV:# R /L SL PMH COPD / ASTHMA / CKD / ESRD / SMOKER / DRUG ABUSE
Site: AC / FA / HAND / WRIST /Ua
CBC / BMP / CMP / ECG or EKG / EEG / CT / MRI / PET / US or
B IVF: Ns /1/2 NS D5 1/2 D5 NS /LR /ABX TEST sonogram / XR or radiograph / BGT / HbA1c/ TFT / UA / PT / aPTT
IV RATE: ml/hr / u/kg/hr
LABS CBC CMP TSH PT Cl Fe
DRIPS: Heparin / Blood / Tpn / Dilt
Central: IJ / PICC PORT / TRIALYSIS VALUES BMP LP HbA1c Na Mg Ca

Medications GENITOURINARY Vital signs

09 AM/PM 08 AM/PM 12 AM/PM
1.
Voiding / Foley / Incontinence / Anuria Temperature:
2. Clear / Cloudy / Yellow / Amber / Bloody Blood Pressure:
3. Respiratory Rate:
BR / Urinal / Bedside Comm / Bedpan Heart Rate:
4. Dialysis: M Tu W Th F Sa Su Oxygen saturation:
NEURO RESPIRATORY MUSCULOSKELETAL SKIN
A Neuro Status: Alert /Oriented / confused/ SpO2 L NC / Room air / NBR / CPAP / BIPAP
Weakness : RUE / LUE / RLE / LLE
→
Intact : Y / N Location :
Site: AC /FA /HAND /WRIST /UA Trach: Wound
Activity: Up and lib / Bed -rest / Walker / Cane / Breath Sounds: Clear / Diminished / Wheezing Size :
Others: Neuro Checks / Restraints / Bed Alarm Treatments: Nebs /IS /CPT Numbness : RUE / LUE / RLE / LLE Location :
Cough: Productive / Non-productive Dressing change :
DRAINS CARDIOVASCULAR GASTROINTESTINAL SCDs Lovenox
Type : Chest Tube / JP / Hemovac / Accordion SB / NSR /ST /A-FIB / A-Flutter / A-Paced / PVCs Diet : Reg / Clear / Full / AHA / ADA Foot Pumps Comadin
Wound Vac AICD / Murmur / Block / Dysphagia / Renal/ NPO Arixtra Heparin
Edema: None / Gen / Trace / 1+ / 2+ /3+ Bowel Activity : Hypo / Active / None Needed
( R / L ) Level :
Pitting / Non-pitting R / L / Bilateral Arms / legs Hyper / Nausea/ Others
Serosanguinous / Sanguineous
Pulses: DP Radial Dopplers / 1+ / 2 Last BM:
Consults Discharge to Notes
R CM / PT / OT / GI / Cards / Neuro
Home / Home Health / ALF / SNF
Nephro / Wound / Ortho / Psych / Surg
 Date.
Patient Name Age Sex Code Ward Emergency contact Care provider
Identification M/F Full Limited

Reason for Medical

S Hospitalization History
DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD
IV:# R /L SL PMH COPD / ASTHMA / CKD / ESRD / SMOKER / DRUG ABUSE
Site: AC / FA / HAND / WRIST /Ua
CBC / BMP / CMP / ECG or EKG / EEG / CT / MRI / PET / US or
B IVF: Ns /1/2 NS D5 1/2 D5 NS /LR /ABX TEST sonogram / XR or radiograph / BGT / HbA1c/ TFT / UA / PT / aPTT
IV RATE: ml/hr / u/kg/hr
LABS CBC CMP TSH PT Cl Fe
DRIPS: Heparin / Blood / Tpn / Dilt
Central: IJ / PICC PORT / TRIALYSIS VALUES BMP LP HbA1c Na Mg Ca

Medications GENITOURINARY Vital signs

09 AM/PM 08 AM/PM 12 AM/PM
1.
Voiding / Foley / Incontinence / Anuria Temperature:
2. Clear / Cloudy / Yellow / Amber / Bloody Blood Pressure:
3. Respiratory Rate:
BR / Urinal / Bedside Comm / Bedpan Heart Rate:
4. Dialysis: M Tu W Th F Sa Su Oxygen saturation:
NEURO RESPIRATORY MUSCULOSKELETAL SKIN
A Neuro Status: Alert /Oriented / confused/ SpO2 L NC / Room air / NBR / CPAP / BIPAP
Weakness : RUE / LUE / RLE / LLE
→
Intact : Y / N Location :
Site: AC /FA /HAND /WRIST /UA Trach: Wound
Activity: Up and lib / Bed -rest / Walker / Cane / Breath Sounds: Clear / Diminished / Wheezing Size :
Others: Neuro Checks / Restraints / Bed Alarm Treatments: Nebs /IS /CPT Numbness : RUE / LUE / RLE / LLE Location :
Cough: Productive / Non-productive Dressing change :
DRAINS CARDIOVASCULAR GASTROINTESTINAL SCDs Lovenox
Type : Chest Tube / JP / Hemovac / Accordion SB / NSR /ST /A-FIB / A-Flutter / A-Paced / PVCs Diet : Reg / Clear / Full / AHA / ADA Foot Pumps Comadin
Wound Vac AICD / Murmur / Block / Dysphagia / Renal/ NPO Arixtra Heparin
Edema: None / Gen / Trace / 1+ / 2+ /3+ Bowel Activity : Hypo / Active / None Needed
( R / L ) Level :
Pitting / Non-pitting R / L / Bilateral Arms / legs Hyper / Nausea/ Others
Serosanguinous / Sanguineous
Pulses: DP Radial Dopplers / 1+ / 2 Last BM:
Consults Discharge to Notes
R CM / PT / OT / GI / Cards / Neuro
Home / Home Health / ALF / SNF
Nephro / Wound / Ortho / Psych / Surg
 Date. / /

Patient Name Age Sex Code Ward Emergency contact Care provider
Identification M/F Full Limited

Reason for Medical

S Hospitalization History
DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD
IV:# R /L SL PMH COPD / ASTHMA / CKD / ESRD / SMOKER / DRUG ABUSE
Site: AC / FA / HAND / WRIST /Ua
CBC / BMP / CMP / ECG or EKG / EEG / CT / MRI / PET / US or
B IVF: Ns /1/2 NS D5 1/2 D5 NS /LR /ABX TEST sonogram / XR or radiograph / BGT / HbA1c/ TFT / UA / PT / aPTT
IV RATE: ml/hr / u/kg/hr
LABS CBC CMP TSH PT Cl Fe
DRIPS: Heparin / Blood / Tpn / Dilt
Central: IJ / PICC PORT / TRIALYSIS VALUES BMP LP HbA1c Na Mg Ca

Medications GENITOURINARY Vital signs

09 AM/PM 08 AM/PM 12 AM/PM
1.
Voiding / Foley / Incontinence / Anuria Temperature:
2. Clear / Cloudy / Yellow / Amber / Bloody Blood Pressure:
3. Respiratory Rate:
BR / Urinal / Bedside Comm / Bedpan Heart Rate:
4. Dialysis: M Tu W Th F Sa Su Oxygen saturation:
NEURO RESPIRATORY MUSCULOSKELETAL SKIN
A Neuro Status: Alert /Oriented / confused/ SpO2 L NC / Room air / NBR / CPAP / BIPAP
Weakness : RUE / LUE / RLE / LLE
→
Intact : Y / N Location :
Site: AC /FA /HAND /WRIST /UA Trach: Wound
Activity: Up and lib / Bed -rest / Walker / Cane / Breath Sounds: Clear / Diminished / Wheezing Size :
Others: Neuro Checks / Restraints / Bed Alarm Treatments: Nebs /IS /CPT Numbness : RUE / LUE / RLE / LLE Location :
Cough: Productive / Non-productive Dressing change :
DRAINS CARDIOVASCULAR GASTROINTESTINAL SCDs Lovenox
Type : Chest Tube / JP / Hemovac / Accordion SB / NSR /ST /A-FIB / A-Flutter / A-Paced / PVCs Diet : Reg / Clear / Full / AHA / ADA Foot Pumps Comadin
Wound Vac AICD / Murmur / Block / Dysphagia / Renal/ NPO Arixtra Heparin
Edema: None / Gen / Trace / 1+ / 2+ /3+ Bowel Activity : Hypo / Active / None Needed
( R / L ) Level :
Pitting / Non-pitting R / L / Bilateral Arms / legs Hyper / Nausea/ Others
Serosanguinous / Sanguineous
Pulses: DP Radial Dopplers / 1+ / 2 Last BM:
Consults Discharge to Notes
R CM / PT / OT / GI / Cards / Neuro
Home / Home Health / ALF / SNF
Nephro / Wound / Ortho / Psych / Surg
 Date. / /

Patient Name Age Sex Code Ward Emergency contact Care provider
Identification M/F Full Limited

Reason for Medical

S Hospitalization History
DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD
IV:# R /L SL PMH COPD / ASTHMA / CKD / ESRD / SMOKER / DRUG ABUSE
Site: AC / FA / HAND / WRIST /Ua
CBC / BMP / CMP / ECG or EKG / EEG / CT / MRI / PET / US or
B IVF: Ns /1/2 NS D5 1/2 D5 NS /LR /ABX TEST sonogram / XR or radiograph / BGT / HbA1c/ TFT / UA / PT / aPTT
IV RATE: ml/hr / u/kg/hr
LABS CBC CMP TSH PT Cl Fe
DRIPS: Heparin / Blood / Tpn / Dilt
Central: IJ / PICC PORT / TRIALYSIS VALUES BMP LP HbA1c Na Mg Ca

Medications GENITOURINARY Vital signs

09 AM/PM 08 AM/PM 12 AM/PM
1.
Voiding / Foley / Incontinence / Anuria Temperature:
2. Clear / Cloudy / Yellow / Amber / Bloody Blood Pressure:
3. Respiratory Rate:
BR / Urinal / Bedside Comm / Bedpan Heart Rate:
4. Dialysis: M Tu W Th F Sa Su Oxygen saturation:
NEURO RESPIRATORY MUSCULOSKELETAL SKIN
A Neuro Status: Alert /Oriented / confused/ SpO2 L NC / Room air / NBR / CPAP / BIPAP
Weakness : RUE / LUE / RLE / LLE
→
Intact : Y / N Location :
Site: AC /FA /HAND /WRIST /UA Trach: Wound
Activity: Up and lib / Bed -rest / Walker / Cane / Breath Sounds: Clear / Diminished / Wheezing Size :
Others: Neuro Checks / Restraints / Bed Alarm Treatments: Nebs /IS /CPT Numbness : RUE / LUE / RLE / LLE Location :
Cough: Productive / Non-productive Dressing change :
DRAINS CARDIOVASCULAR GASTROINTESTINAL SCDs Lovenox
Type : Chest Tube / JP / Hemovac / Accordion SB / NSR /ST /A-FIB / A-Flutter / A-Paced / PVCs Diet : Reg / Clear / Full / AHA / ADA Foot Pumps Comadin
Wound Vac AICD / Murmur / Block / Dysphagia / Renal/ NPO Arixtra Heparin
Edema: None / Gen / Trace / 1+ / 2+ /3+ Bowel Activity : Hypo / Active / None Needed
( R / L ) Level :
Pitting / Non-pitting R / L / Bilateral Arms / legs Hyper / Nausea/ Others
Serosanguinous / Sanguineous
Pulses: DP Radial Dopplers / 1+ / 2 Last BM:
Consults Discharge to Notes
R CM / PT / OT / GI / Cards / Neuro
Home / Home Health / ALF / SNF
Nephro / Wound / Ortho / Psych / Surg
 Date. / /

Patient Name Age Sex Code Ward Emergency contact Care provider
Identification M/F Full Limited

Reason for Medical

S Hospitalization History
DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD
IV:# R /L SL PMH COPD / ASTHMA / CKD / ESRD / SMOKER / DRUG ABUSE
Site: AC / FA / HAND / WRIST /Ua
CBC / BMP / CMP / ECG or EKG / EEG / CT / MRI / PET / US or
B IVF: Ns /1/2 NS D5 1/2 D5 NS /LR /ABX TEST sonogram / XR or radiograph / BGT / HbA1c/ TFT / UA / PT / aPTT
IV RATE: ml/hr / u/kg/hr
LABS CBC CMP TSH PT Cl Fe
DRIPS: Heparin / Blood / Tpn / Dilt
Central: IJ / PICC PORT / TRIALYSIS VALUES BMP LP HbA1c Na Mg Ca

Medications GENITOURINARY Vital signs

09 AM/PM 08 AM/PM 12 AM/PM
1.
Voiding / Foley / Incontinence / Anuria Temperature:
2. Clear / Cloudy / Yellow / Amber / Bloody Blood Pressure:
3. Respiratory Rate:
BR / Urinal / Bedside Comm / Bedpan Heart Rate:
4. Dialysis: M Tu W Th F Sa Su Oxygen saturation:
NEURO RESPIRATORY MUSCULOSKELETAL SKIN
A Neuro Status: Alert /Oriented / confused/ SpO2 L NC / Room air / NBR / CPAP / BIPAP
Weakness : RUE / LUE / RLE / LLE
→
Intact : Y / N Location :
Site: AC /FA /HAND /WRIST /UA Trach: Wound
Activity: Up and lib / Bed -rest / Walker / Cane / Breath Sounds: Clear / Diminished / Wheezing Size :
Others: Neuro Checks / Restraints / Bed Alarm Treatments: Nebs /IS /CPT Numbness : RUE / LUE / RLE / LLE Location :
Cough: Productive / Non-productive Dressing change :
DRAINS CARDIOVASCULAR GASTROINTESTINAL SCDs Lovenox
Type : Chest Tube / JP / Hemovac / Accordion SB / NSR /ST /A-FIB / A-Flutter / A-Paced / PVCs Diet : Reg / Clear / Full / AHA / ADA Foot Pumps Comadin
Wound Vac AICD / Murmur / Block / Dysphagia / Renal/ NPO Arixtra Heparin
Edema: None / Gen / Trace / 1+ / 2+ /3+ Bowel Activity : Hypo / Active / None Needed
( R / L ) Level :
Pitting / Non-pitting R / L / Bilateral Arms / legs Hyper / Nausea/ Others
Serosanguinous / Sanguineous
Pulses: DP Radial Dopplers / 1+ / 2 Last BM:
Consults Discharge to Notes
R CM / PT / OT / GI / Cards / Neuro
Home / Home Health / ALF / SNF
Nephro / Wound / Ortho / Psych / Surg