ROOM

CODE

PRECAUTIONS
Restraints Suicide
Fall
Aspiration
Seizure ETOH
Isolation:
ALLERGIES

MD / CONSULTS

DX

HX

SOCIAL HX
Tobacco
Alcohol
Drugs
VACCINES
PNA
FLU

DIAGNOSTICS

E+/- PROTOCOL

LABS

Na
mOsm
K
Mg
Phos
iCa
AGap
ABG

CULTURES

pH:
FiO2:

CO2:

O2:

HCO3:

BE:

pH:
FiO2:

CO2:

O2:

HCO3:

BE:

pH:
FiO2:

CO2:

O2:

HCO3:

BE:

ANTIBIOTICS

IV SITES & DRIPS

PICC Other

BLOOD PRODUCTS
Consent
PRBC
FFP
PLT
OTHER
PIV

CVC IVAD

PRN

LAST V/S
Pain:

HR:
Wt:

BP:

RR:

CVP:
SVo2:
NEURO

ART:

PAP:

SaO2:

Intake

Net

Output

CO:

CARDIO

PULMO

VENT SETTINGS
Mode:

GI / ENDO

fio2:
p:

vt:

r:

ps:

mv:

TUBEFEEDING
Formula:
Rate:
TFR:

Gl:

Flush:

Q:

GU

ORTHO
RISK Hx

FALL

Lines / Tubes / Drains

DVT PROPHYLAXIS
SCDs Heparin
Lovenox
Drip

ACCUCHEK Q:

GI PROPHYLAXIS
Protonix Pepcid
Drip
SKIN

NOTES / RECOMMENDATIONS

REPORT FROM:
TO:

TO DO

REPORTED

FAMILY

PLAN

MED-PASS

REQUIRED DOCUMENTATIONS
Admission
POC / Pt
Ed
Assess/Reassess
D/C
V/S, Pain, RASS
Wt, I&O