Room
Name
Age
Day #
Code
Allergies
Provider
Weight
Admitted for · diagnoses
Precautions · mobility
ContactDropletAirborneFall risk
SelfAssist ×1Assist ×2TotalLift
Problems · what we are doing
Access
PIVCentralPICCPortFoleyDrips · fluids
Patches
FentanylNitroLidoSkin — mark the spot, describe it below
front · back
IntactDTIStage 1234UnstageableBruiseRash
1
2
3
4
5
6
BM · bowel
Last BM
This shiftIncont.Ostomy
Diet
RegularNPOThickenedTubeAspirationI & O
| In | Out |
|---|---|
Vitals
| Time | BP | HR | RR | Temp | SpO₂ |
|---|---|---|---|---|---|
Glucose · O₂ · tele
| Time | CBG | Cover |
|---|---|---|
Room airNCTele
Ask in report
Changes this shift — time · what happened
Procedures · pending
Notes
Not a medical record. Shred at end of shift.Date ________ · Shift ________