Dx/Surg:_________________ Dx/Surg:_________________

Rm:______________________ Nurse:___________________ Rm:______________________ Nurse:___________________

Isolation:________________ Allergies:________________ Isolation:________________ Allergies:________________
Dr:_______________________ Wt BO:___________________ Dr:_______________________ Wt BO:___________________
Diet:_____________________ Dressings:____________ Diet:_____________________ Dressings:____________
Analgesia/LD:__________ PCA check:___________ Analgesia/LD:__________ PCA check:___________

Safety Checks:__________ Hygiene: wash______ Oral_______ Safety Checks:__________ Hygiene: wash______ Oral_______
LBM:______________ BProt?____Foley:____________ LBM:______________ BProt?____Foley:____________
Vitals: Vitals:
Time: BP HR RR Temp 02 sat Pain /10 Time: BP HR RR Temp 02 sat Pain /10

Assessment (Head to Toe): Assessment (Head to Toe):

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IV Placement:_____________
BGM: _________(730) ___________(1130)__________(1730)
Labs:_________________________________________________________________________________________________
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Hx:___________________________________________________________________________________________________
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Time Task Time Task
0630 1000
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IV Placement:_____________
BGM: _________(730) ___________(1130)__________(1730)
Labs:_________________________________________________________________________________________________
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Hx:___________________________________________________________________________________________________
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Time Task Time Task
0630 1000

0700 1030 0700 1030

0730 1100 0730 1100

0800 1130 0800 1130

0830 1200 0830 1200

0900 1230 0900 1230

0930 1300 0930 1300