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Brain 1

This document contains a medical history and hospital course for a patient. It includes information about their age, sex, room number, admission date, length of stay, allergies, admission diagnosis, procedure, code status, past medical history, vital signs, lab results, hospital treatments and plans of care. The summary focuses on the high level details across key areas like neurology, cardiology, respiratory and more. Variances and discharge planning are also documented.

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Nurse Betty
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© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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11K views1 page

Brain 1

This document contains a medical history and hospital course for a patient. It includes information about their age, sex, room number, admission date, length of stay, allergies, admission diagnosis, procedure, code status, past medical history, vital signs, lab results, hospital treatments and plans of care. The summary focuses on the high level details across key areas like neurology, cardiology, respiratory and more. Variances and discharge planning are also documented.

Uploaded by

Nurse Betty
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Todays Date: ___/___/___ Patient: __________________________ Age: ___ Sex: ___ Rm: ____ Admit Date: ___/___/___ HD:

________ LOS: _______ Allergies: __________________________ Admit Diagnosis: _________________________ Procedure: _____________ Code Status: ______ Comorbid Conditions\Hx: ____________________________________________________________
SIGNIFICANT HOSPITAL HISTORY
NEURO: Orientation: Psych/Soc: Pupils: Extremity Strength: Temp: Activity: Weight: Fall Precaution: Restraints: CV: Rhythm: HR: BP: A Line Swan Ganz: PA PAWP CVP: CO Pacer Wires: K+: CPK: CBC: Hct: PT: Mg+: MBs: Trop: Hgb: PTT: Ca: Edema (slight=+1/mod=+2/pitting=+3): Pulses (absent=0/weak=1/strong=2): (R) (L) PICC/Central line/ IJ: Hep Lock: DRIPS: cc/hr PULM: Extub: BS: Coughing: Chest Tubes: ABG: GI: BS: NG: Diet: Feeding: Chemstrip: GU: Foley: Urine Output: RR: Sputum: Bipap: Mode: FiO2: TV rate: Abd Contour: Flatus: pH: BM: Appetite: Cath Care: PD: Hemo: O2: Mask: Triflow: Cuff Pressure: GI: PLAN: VARIANCE

BODY SYSTEMS
NEURO: PLAN: VARIANCE

CV:

PLAN:

VARIANCE

RESP:

PLAN:

VARIANCE

SG:

GU: I&Os:

PLAN:

VARIANCE

Skin/Dressing/Incisions: Braden Scale: Other: Discharge Plan: Variance to Discharge Plan: Barrier Resolution: Consults:

Specimens: Tests/Labs: Proc/Hx/Preps: Other: Teaching/Learning: Consults: Special Needs:

Ca: Mg:

PTT: PT:

CPK: CKMB:

CKMB%: TROP:

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