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code status isolation neuro

loc & orientation strength & sensation pupils gcs icp

allergies rass bis

md

cardiovascular
dx rhythm & rate blood pressure edema pulses

bp goal / prn temps

iv access

pulmonary
airway lung sounds secretions chest tubes

vent / cpap / bipap settings


medical hx surgical hx

gastro / endo
diet / tube abdomen bs & lbm symptoms / regimen

family / poa / advance directives formula accucheks

genitourinary
ppx vaccines voiding / foley urine quality uo diuretics

labs abg

crrt / cvvh

musculoskeletal
activity / pt / ot devices

cultures serial labs


integumentary
treatment

antibiotics drips

notes
blood products

prn meds prn given

diagnostic imaging