Room #: Code: MD:

Dx: Allergies:

SITUATION Safety: ❑ Confused ❑ Fall ❑ Restraints ❑ Alarm ❑ Suicide BACKGROUND

Isolation: ❑ None ❑ Contact ❑ Droplet ❑ Airborne ❑ Neutropenic
Admit Date: ______ From: ______ Reason: _____________________ Tests Done PMH: Psychosocial:
Hospital Course:

Decision Maker:

ASSESSMENT
Temperature Neuro: 4 3 2 1 ❑ EVD Cardiac Hemodynamics ❑ A-Line
NOC T-Max _____ Day T-Max _____ EF: ______ Echo Date: _____________ ❑ CVP Monitor
RASS _______ CAM +- ❑ Swann
Rhythm: _________________________
Pain

GCS _____________________________
Respiratory ❑ Clear Vent Settings ❑ RT GI GU
❑ ET ❑ ARDS ❑ NG ❑ OG ❑ PEG ❑ LWS ______ ❑ Foley ❑ BSC ❑ BRP ❑ Anuric ❑ Dialysis
❑ Trach C-Diff: - + Last BM: _________
❑ Ch T MODE ________ FiO2 ____________ NOCS DAYS
❑ IS In ______ Out______ In ______ Out ______
PS ___________ PEEP ___________ In ______ Out ______ In ______ Out ______
In ______ Out ______ In ______ Out ______
Vt ____________ RATE ____________ Diet
Fluid Balance
P/F Ratio: _____

Muskuloskeletal Skin Drains IV Sites

❑ Clear ❑ Dsng: _________________ ❑ PIV:
❑ Wounds: ______________________
❑ Central:

❑ PICC:
❑ SCDs ❑ TEDs DVT & Stress Ulcer Prophylaxis: Immune System
❑ Boots ❑ Special Bed ❑ Heparin ❑ Lovenox ❑ SCDs Flu: ❑ Needs ❑ Received ❑ Other:
❑ Sling ❑ Ambulating ❑ Pepcid ❑ Protonix PNA: ❑ Needs ❑ Received
MRSA: ❑ Admit ❑ > 7 Days in ICU
Gtts Sepsis: ❑ Infection ❑ Simple ❑ Severe Lab Draws ❑ K Parameters
1) ___________________ @ ________ Lactate: __________ CVP: _______ ScVO2: ________ ❑ Mg
2) ___________________ @ ________ ❑ Ph
❑ Abx: _____________________ Given @ :_________ ❑ Ca
3) ___________________ @ ________
❑ Abx: _____________________ Given @: _________ PRNs Given
4) ___________________ @ ________
5) ___________________ @ ________ ❑ Abx: _____________________ Given @: _________
6) ___________________ @ ________ ❑ Abx: _____________________ Given @:_________ Accu-Check:
7) ___________________ @ ________ Cultures: ❑ Blood x2 ❑ Urine ❑ Sputum
RECOMMENDATION / PT NEEDS TO-DO LIST Na: _____ ______ ______ K: _____ ______ ______
Mg: _____ ______ ______ Ca: _____ ______ ______
Ph: _____ ______ ______ Cr: _____ ______ ______
BUN: _____ ______ ______ WBC: _____ ______ ______
Hgb: _____ ______ ______ PLT: _____ ______ ______
PT: _____ ______ ______ INR: _____ ______ ______
Lactate: _____ ______ ______ HCO3: _____ ______ ______
Other:
MISC
 Room #: Code: MD:
Dx: Allergies:

SITUATION Safety: ❑ Confused ❑ Fall ❑ Restraints ❑ Alarm ❑ Suicide BACKGROUND

Isolation: ❑ None ❑ Contact ❑ Droplet ❑ Airborne ❑ Neutropenic
Admit Date: ______ From: ______ Reason: _____________________ Tests Done PMH: Psychosocial:
Hospital Course:

Decision Maker:

ASSESSMENT
Temperature Neuro: 4 3 2 1 ❑ EVD Cardiac Hemodynamics ❑ A-Line
NOC T-Max _____ Day T-Max _____ EF: ______ Echo Date: _____________ ❑ CVP Monitor
RASS _______ CAM +- ❑ Swann
Rhythm: _________________________
Pain

GCS _____________________________

Respiratory ❑ Clear Vent Settings ❑ RT GI GU

❑ ET ❑ ARDS ❑ NG ❑ OG ❑ PEG ❑ LWS ______ ❑ Foley ❑ BSC ❑ BRP ❑ Anuric ❑ Dialysis
❑ Trach C-Diff: - + Last BM: _________
❑ Ch T MODE ________ FiO2 ____________ NOCS DAYS
❑ IS In ______ Out______ In ______ Out ______
PS ___________ PEEP ___________ In ______ Out ______ In ______ Out ______
In ______ Out ______ In ______ Out ______
Vt ____________ RATE ____________ Diet
Fluid Balance
P/F Ratio: _____

Muskuloskeletal Skin Drains IV Sites

❑ Clear ❑ Dsng: _________________ ❑ PIV:
❑ Wounds: ______________________
❑ Central:

❑ PICC:
❑ SCDs ❑ TEDs DVT & Stress Ulcer Prophylaxis: Immune System
❑ Boots ❑ Special Bed ❑ Heparin ❑ Lovenox ❑ SCDs Flu: ❑ Needs ❑ Received ❑ Other:
❑ Sling ❑ Ambulating ❑ Pepcid ❑ Protonix PNA: ❑ Needs ❑ Received
MRSA: ❑ Admit ❑ > 7 Days in ICU
Gtts Sepsis: ❑ Infection ❑ Simple ❑ Severe Lab Draws ❑ K Parameters
1) ___________________ @ ________ Lactate: __________ CVP: _______ ScVO2: ________ ❑ Mg
2) ___________________ @ ________ ❑ Ph
❑ Abx: _____________________ Given @ :_________ ❑ Ca
3) ___________________ @ ________
❑ Abx: _____________________ Given @: _________ PRNs Given
4) ___________________ @ ________
5) ___________________ @ ________ ❑ Abx: _____________________ Given @: _________
6) ___________________ @ ________ ❑ Abx: _____________________ Given @:_________ Accu-Check:
7) ___________________ @ ________ Cultures: ❑ Blood x2 ❑ Urine ❑ Sputum
RECOMMENDATION / PT NEEDS TO-DO LIST Na: _____ ______ ______ K: _____ ______ ______
Mg: _____ ______ ______ Ca: _____ ______ ______
Ph: _____ ______ ______ Cr: _____ ______ ______
BUN: _____ ______ ______ WBC: _____ ______ ______
Hgb: _____ ______ ______ PLT: _____ ______ ______
PT: _____ ______ ______ INR: _____ ______ ______
Lactate: _____ ______ ______ HCO3: _____ ______ ______
Other:
MISC
 Room #: Code: MD:
Dx: Allergies:

SITUATION Safety: ❑ Confused ❑ Fall ❑ Restraints ❑ Alarm ❑ Suicide BACKGROUND

Isolation: ❑ None ❑ Contact ❑ Droplet ❑ Airborne ❑ Neutropenic
Admit Date: ______ From: ______ Reason: _____________________ Tests Done PMH: Psychosocial:
Hospital Course:

Decision Maker:

ASSESSMENT
Temperature Neuro: 4 3 2 1 ❑ EVD Cardiac Hemodynamics ❑ A-Line
NOC T-Max _____ Day T-Max _____ EF: ______ Echo Date: _____________ ❑ CVP Monitor
RASS _______ CAM +- ❑ Swann
Rhythm: _________________________
Pain

GCS _____________________________
Respiratory ❑ Clear Vent Settings ❑ RT GI GU
❑ ET ❑ ARDS ❑ NG ❑ OG ❑ PEG ❑ LWS ______ ❑ Foley ❑ BSC ❑ BRP ❑ Anuric ❑ Dialysis
❑ Trach C-Diff: - + Last BM: _________
❑ Ch T MODE ________ FiO2 ____________ NOCS DAYS
❑ IS In ______ Out______ In ______ Out ______
PS ___________ PEEP ___________ In ______ Out ______ In ______ Out ______
In ______ Out ______ In ______ Out ______
Vt ____________ RATE ____________ Diet
Fluid Balance
P/F Ratio: _____

Muskuloskeletal Skin Drains IV Sites

❑ Clear ❑ Dsng: _________________ ❑ PIV:
❑ Wounds: ______________________
❑ Central:

❑ PICC:
❑ SCDs ❑ TEDs DVT & Stress Ulcer Prophylaxis: Immune System
❑ Boots ❑ Special Bed ❑ Heparin ❑ Lovenox ❑ SCDs Flu: ❑ Needs ❑ Received ❑ Other:
❑ Sling ❑ Ambulating ❑ Pepcid ❑ Protonix PNA: ❑ Needs ❑ Received
MRSA: ❑ Admit ❑ > 7 Days in ICU
Gtts Sepsis: ❑ Infection ❑ Simple ❑ Severe Lab Draws ❑ K Parameters
1) ___________________ @ ________ Lactate: __________ CVP: _______ ScVO2: ________ ❑ Mg
2) ___________________ @ ________ ❑ Ph
❑ Abx: _____________________ Given @ :_________ ❑ Ca
3) ___________________ @ ________
❑ Abx: _____________________ Given @: _________ PRNs Given
4) ___________________ @ ________
5) ___________________ @ ________ ❑ Abx: _____________________ Given @: _________
6) ___________________ @ ________ ❑ Abx: _____________________ Given @:_________ Accu-Check:
7) ___________________ @ ________ Cultures: ❑ Blood x2 ❑ Urine ❑ Sputum
RECOMMENDATION / PT NEEDS TO-DO LIST Na: _____ ______ ______ K: _____ ______ ______
Mg: _____ ______ ______ Ca: _____ ______ ______
Ph: _____ ______ ______ Cr: _____ ______ ______
BUN: _____ ______ ______ WBC: _____ ______ ______
Hgb: _____ ______ ______ PLT: _____ ______ ______
PT: _____ ______ ______ INR: _____ ______ ______
Lactate: _____ ______ ______ HCO3: _____ ______ ______
Other:
MISC
 Room #: Code: MD:
Dx: Allergies:

SITUATION Safety: ❑ Confused ❑ Fall ❑ Restraints ❑ Alarm ❑ Suicide BACKGROUND

Isolation: ❑ None ❑ Contact ❑ Droplet ❑ Airborne ❑ Neutropenic
Admit Date: ______ From: ______ Reason: _____________________ Tests Done PMH: Psychosocial:
Hospital Course:

Decision Maker:

ASSESSMENT
Temperature Neuro: 4 3 2 1 ❑ EVD Cardiac Hemodynamics ❑ A-Line
NOC T-Max _____ Day T-Max _____ EF: ______ Echo Date: _____________ ❑ CVP Monitor
RASS _______ CAM +- ❑ Swann
Rhythm: _________________________
Pain

GCS _____________________________
Respiratory ❑ Clear Vent Settings ❑ RT GI GU
❑ ET ❑ ARDS ❑ NG ❑ OG ❑ PEG ❑ LWS ______ ❑ Foley ❑ BSC ❑ BRP ❑ Anuric ❑ Dialysis
❑ Trach C-Diff: - + Last BM: _________
❑ Ch T MODE ________ FiO2 ____________ NOCS DAYS
❑ IS In ______ Out______ In ______ Out ______
PS ___________ PEEP ___________ In ______ Out ______ In ______ Out ______
In ______ Out ______ In ______ Out ______
Vt ____________ RATE ____________ Diet
Fluid Balance
P/F Ratio: _____

Muskuloskeletal Skin Drains IV Sites

❑ Clear ❑ Dsng: _________________ ❑ PIV:
❑ Wounds: ______________________
❑ Central:

❑ PICC:
❑ SCDs ❑ TEDs DVT & Stress Ulcer Prophylaxis: Immune System
❑ Boots ❑ Special Bed ❑ Heparin ❑ Lovenox ❑ SCDs Flu: ❑ Needs ❑ Received ❑ Other:
❑ Sling ❑ Ambulating ❑ Pepcid ❑ Protonix PNA: ❑ Needs ❑ Received
MRSA: ❑ Admit ❑ > 7 Days in ICU
Gtts Sepsis: ❑ Infection ❑ Simple ❑ Severe Lab Draws ❑ K Parameters
1) ___________________ @ ________ Lactate: __________ CVP: _______ ScVO2: ________ ❑ Mg
2) ___________________ @ ________ ❑ Ph
❑ Abx: _____________________ Given @ :_________ ❑ Ca
3) ___________________ @ ________
❑ Abx: _____________________ Given @: _________ PRNs Given
4) ___________________ @ ________
5) ___________________ @ ________ ❑ Abx: _____________________ Given @: _________
6) ___________________ @ ________ ❑ Abx: _____________________ Given @:_________ Accu-Check:
7) ___________________ @ ________ Cultures: ❑ Blood x2 ❑ Urine ❑ Sputum
RECOMMENDATION / PT NEEDS TO-DO LIST Na: _____ ______ ______ K: _____ ______ ______
Mg: _____ ______ ______ Ca: _____ ______ ______
Ph: _____ ______ ______ Cr: _____ ______ ______
BUN: _____ ______ ______ WBC: _____ ______ ______
Hgb: _____ ______ ______ PLT: _____ ______ ______
PT: _____ ______ ______ INR: _____ ______ ______
Lactate: _____ ______ ______ HCO3: _____ ______ ______
Other:
MISC
 Room #: Code: MD:
Dx: Allergies:

SITUATION Safety: ❑ Confused ❑ Fall ❑ Restraints ❑ Alarm ❑ Suicide BACKGROUND

Isolation: ❑ None ❑ Contact ❑ Droplet ❑ Airborne ❑ Neutropenic
Admit Date: ______ From: ______ Reason: _____________________ Tests Done PMH: Psychosocial:
Hospital Course:

Decision Maker:

ASSESSMENT
Temperature Neuro: 4 3 2 1 ❑ EVD Cardiac Hemodynamics ❑ A-Line
NOC T-Max _____ Day T-Max _____ EF: ______ Echo Date: _____________ ❑ CVP Monitor
RASS _______ CAM +- ❑ Swann
Rhythm: _________________________
Pain

GCS _____________________________
Respiratory ❑ Clear Vent Settings ❑ RT GI GU
❑ ET ❑ ARDS ❑ NG ❑ OG ❑ PEG ❑ LWS ______ ❑ Foley ❑ BSC ❑ BRP ❑ Anuric ❑ Dialysis
❑ Trach C-Diff: - + Last BM: _________
❑ Ch T MODE ________ FiO2 ____________ NOCS DAYS
❑ IS In ______ Out______ In ______ Out ______
PS ___________ PEEP ___________ In ______ Out ______ In ______ Out ______
In ______ Out ______ In ______ Out ______
Vt ____________ RATE ____________ Diet
Fluid Balance
P/F Ratio: _____

Muskuloskeletal Skin Drains IV Sites

❑ Clear ❑ Dsng: _________________ ❑ PIV:
❑ Wounds: ______________________
❑ Central:

❑ PICC:
❑ SCDs ❑ TEDs DVT & Stress Ulcer Prophylaxis: Immune System
❑ Boots ❑ Special Bed ❑ Heparin ❑ Lovenox ❑ SCDs Flu: ❑ Needs ❑ Received ❑ Other:
❑ Sling ❑ Ambulating ❑ Pepcid ❑ Protonix PNA: ❑ Needs ❑ Received
MRSA: ❑ Admit ❑ > 7 Days in ICU
Gtts Sepsis: ❑ Infection ❑ Simple ❑ Severe Lab Draws ❑ K Parameters
1) ___________________ @ ________ Lactate: __________ CVP: _______ ScVO2: ________ ❑ Mg
2) ___________________ @ ________ ❑ Ph
❑ Abx: _____________________ Given @ :_________ ❑ Ca
3) ___________________ @ ________
❑ Abx: _____________________ Given @: _________ PRNs Given
4) ___________________ @ ________
5) ___________________ @ ________ ❑ Abx: _____________________ Given @: _________
6) ___________________ @ ________ ❑ Abx: _____________________ Given @:_________ Accu-Check:
7) ___________________ @ ________ Cultures: ❑ Blood x2 ❑ Urine ❑ Sputum
RECOMMENDATION / PT NEEDS TO-DO LIST Na: _____ ______ ______ K: _____ ______ ______
Mg: _____ ______ ______ Ca: _____ ______ ______
Ph: _____ ______ ______ Cr: _____ ______ ______
BUN: _____ ______ ______ WBC: _____ ______ ______
Hgb: _____ ______ ______ PLT: _____ ______ ______
PT: _____ ______ ______ INR: _____ ______ ______
Lactate: _____ ______ ______ HCO3: _____ ______ ______
Other:
MISC
Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____ Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____

Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________ Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________
PMH Background Plan PMH Background Plan

Neuro 4 3 2 1 Cardiac EF: ______ Resp GI NG/GT/JT Neuro 4 3 2 1 Cardiac EF: ______ Resp GI NG/GT/JT
DW: ______ Sat ____% on _______ Last BM: DW: ______ Sat ____% on _______ Last BM:
Tx Diet: Tx Diet:

GU IV Sites IV Fluids Skin GU IV Sites IV Fluids Skin

Amber Void _________ on _______ Amber Void _________ on _______
Yellow Foley Yellow Foley
Straw BSC _________ on _______ Straw BSC _________ on _______
Clr/Cldy Inct Dsng ! Clr/Cldy Inct Dsng !
Odor UTI Odor UTI
! site / tubing ! site / tubing

Drains/Tubes Accu ! AC HS Time Tmp HR RR O2 BP Pain Drains/Tubes Accu ! AC HS Time Tmp HR RR O2 BP Pain
_______ @ _______ _______ @ _______
_____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
_______ @ _______ _______ @ _______
_____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
_______ @ _______ _______ @ _______
Draws Draws
_____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
Previous PRNs Previous PRNs
_____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____

Intake & Output PRNs given Precautions: F Bld ASP Sz Cont Air Drop Intake & Output PRNs given Precautions: F Bld ASP Sz Cont Air Drop
PS: / _________ @ _______ Activity: Ad lib Br ___º BRP AMB OOB/Ch PS: / _________ @ _______ Activity: Ad lib Br ___º BRP AMB OOB/Ch
+ / - _____ @ _______ _________ @ _______ Allergies: NKDA __________________________ + / - _____ @ _______ _________ @ _______ Allergies: NKDA __________________________
+ / - _____ @ _______ + / - _____ @ _______
_________ @ _______ WBC ____ PT _____ K ____, _____ _________ @ _______ WBC ____ PT _____ K ____, _____
+ / - _____ @ _______ + / - _____ @ _______
_________ @ _______ Hgb _____ INR ____ Mg ____ _________ @ _______ Hgb _____ INR ____ Mg ____
+ / - _____ @ _______ + / - _____ @ _______
+ / - _____ @ _______ _________ @ _______ Hct _____ BUN ____ Trop ____, ___, ____ + / - _____ @ _______ _________ @ _______ Hct _____ BUN ____ Trop ____, ___, ____
IN: _____ Out: _____ PLT ____ Cr _____ IN: _____ Out: _____ PLT ____ Cr _____
To Do: To Do:
Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____ Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____

Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________ Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________
PMH Background Plan PMH Background Plan

Neuro 4 3 2 1 Cardiac EF: ______ Resp GI NG/GT/JT Neuro 4 3 2 1 Cardiac EF: ______ Resp GI NG/GT/JT
DW: ______ Sat ____% on _______ Last BM: DW: ______ Sat ____% on _______ Last BM:
Tx Diet: Tx Diet:

GU IV Sites IV Fluids Skin GU IV Sites IV Fluids Skin

Amber Void _________ on _______ Amber Void _________ on _______
Yellow Foley Yellow Foley
Straw BSC _________ on _______ Straw BSC _________ on _______
Clr/Cldy Inct Dsng ! Clr/Cldy Inct Dsng !
Odor UTI Odor UTI
! site / tubing ! site / tubing

Drains/Tubes Accu ! AC HS Time Tmp HR RR O2 BP Pain Drains/Tubes Accu ! AC HS Time Tmp HR RR O2 BP Pain
_______ @ _______ _______ @ _______
_____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
_______ @ _______ _______ @ _______
_____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
_______ @ _______ _______ @ _______
Draws Draws
_____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
Previous PRNs Previous PRNs
_____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____

Intake & Output PRNs given Precautions: F Bld ASP Sz Cont Air Drop Intake & Output PRNs given Precautions: F Bld ASP Sz Cont Air Drop
PS: / _________ @ _______ Activity: Ad lib Br ___º BRP AMB OOB/Ch PS: / _________ @ _______ Activity: Ad lib Br ___º BRP AMB OOB/Ch
+ / - _____ @ _______ _________ @ _______ Allergies: NKDA __________________________ + / - _____ @ _______ _________ @ _______ Allergies: NKDA __________________________
+ / - _____ @ _______ + / - _____ @ _______
_________ @ _______ WBC ____ PT _____ K ____, _____ _________ @ _______ WBC ____ PT _____ K ____, _____
+ / - _____ @ _______ + / - _____ @ _______
_________ @ _______ Hgb _____ INR ____ Mg ____ _________ @ _______ Hgb _____ INR ____ Mg ____
+ / - _____ @ _______ + / - _____ @ _______
+ / - _____ @ _______ _________ @ _______ Hct _____ BUN ____ Trop ____, ___, ____ + / - _____ @ _______ _________ @ _______ Hct _____ BUN ____ Trop ____, ___, ____
IN: _____ Out: _____ PLT ____ Cr _____ IN: _____ Out: _____ PLT ____ Cr _____
To Do: To Do: