7 8 9 10 11 12 1 2 3 4 5 6 7

Rm: Allergies: Code:_______ MEWS:____

O2:__________ S/L:__________ Diet:____________ Assessment

IV:_________________ Infused:A_______B:_______
T:_____ P:_____ R:_____ B/P:________ O2:______
T:_____ P:_____ R:_____ B/P:________ O2:______
T:_____ P:_____ R:_____ B/P:________ O2:______
Accu : 0700_____ 1130_____ 1630____ 2100____
BRP / foley / BSC / urinal UA / C&S stools x ____
Activity: ↑ad lib / bed rest / ↑in chair / O2 walks / assist
Precautions: contact / fall / seizure / aspiration / neuro  F B
PCA Drug:__________ Dose:___mg/___ml; ___ml/hr
0800 ATT:___ INJ:___ 1000 ATT:___ INJ:___
1200 ATT:___ INJ:___ 1400 ATT:___ INJ:___
1600 ATT:___ INJ:___ 1800 ATT:___ INJ:___ Mg
Hgb Na Cl BUN
Total ml INJ:________ WBC Plt Glu PTT PT INR
Hct K+ CO2 Cr Ca PO4

7 8 9 10 11 12 1 2 3 4 5 6 7

Rm: Allergies: Code:_______ MEWS:____

O2:__________ S/L:__________ Diet:____________ Assessment

IV:_________________ Infused:A_______B:_______
T:_____ P:_____ R:_____ B/P:________ O2:______
T:_____ P:_____ R:_____ B/P:________ O2:______
T:_____ P:_____ R:_____ B/P:________ O2:______
Accu : 0700____ 1130____ 1630_____ 2100_____
BRP / foley / BSC / urinal UA / C&S stools x ____
Activity: ↑ad lib / bed rest / ↑in chair / O2 walks / assist
Precautions: contact / fall / seizure / aspiration / neuro  F B
PCA Drug:__________ Dose:___mg/___ml; ___ml/hr
0800 ATT:___ INJ:___ 1000 ATT:___ INJ:___
1200 ATT:___ INJ:___ 1400 ATT:___ INJ:___
1600 ATT:___ INJ:___ 1800 ATT:___ INJ:___ Hgb Mg
Na Cl BUN PTT
WBC Plt Glu Ca PO4 PT INR
Total ml INJ:________ Hct K+ CO2 Cr