S

Patient name Age Room number date 1 Dx C/O Admit

allergies

Physician Attending

Code status Advanced directive on chart?

Consultants Pgr/#

2 Dx

B A

History Surgery: Anesthesia Surgeon Anesthesiologist EBL

Isolation Restraints Fall risk

Core Measures CHF MI PNA Vaccine- PNA Flu

Cardiac: BP/HR/Peripheral pulses/Edema/Heart sounds Current rhythm Daily wt? DVT prophylaxis Pulmonary: Breath sounds/Secretions/ SpO2/UPAs/PIP/ Spontaneous VT & VE Vent/bipap etc settings

Pain/sedation Pain scale Location Meds type and last dose Accu checks Frequency Last Results A1C

GI BS

NG/OGT Last BM Diet Prophylaxis GI

Skin Wounds/Drainage Staples Drains Location Ducub photo on admission Date inserted Gtts Pending orders Psych Social

GU Foley/void Output

IV Fluids Meds

Na

Cl

Bun

gluc

mg

BNP

Coags INR W Pl

Hct

UA

CT CXR

Co

Cr

Ca

Phos

DDimer

PTT Next lab

Cultures

MRI Echo

Cardiac enz

Hgb Shift goals

DC Plan. Is pt informed of plan___ 24 hour orders reviewed____