ALERT COMPREHENSIVE SPECIALIZED HOSPITAL

DKA (Diabetic Ketoacidosis) FOLLOW UP SHEET

NAME: AGE: SEX: MRN NO: - WARD: - Bed number:

DATE TIME PR RR TO SP02 Mentation Vomiting RBS/FBS Fluid URINE REGULAR IN PUT OUT Other SIGN
type KETONE INSULIN PUT Rx
given

REMARK: - The number of times all parameters be measured will depend on physician’s order, and the patient condition.
To be filled by any health worker that is following the patient accordingly.
Under the input column (i.e. Bolus, NPO, ORS per loss, NG tube, and PO feeding,)
Under the other Rx given column (i.e. D10 IV PUSH, etc….)