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    Nursing Brains

    Uploaded by

    Michael Kim
    This document contains a patient assessment form with sections for situation, background, assessment, recommendations, and to-do list. The assessment includes vital signs, neurological status, respiratory status, cardiovascular function, gastrointestinal/genitourinary systems, musculoskeletal issues, skin, drains, IV access, immune status, labs, medications and fluid balance. It provides a comprehensive overview of the patient's current condition and medical needs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Nursing Brains

    Uploaded by

    Michael Kim
    75 views7 pages
    This document contains a patient assessment form with sections for situation, background, assessment, recommendations, and to-do list. The assessment includes vital signs, neurological status, respiratory status, cardiovascular function, gastrointestinal/genitourinary systems, musculoskeletal issues, skin, drains, IV access, immune status, labs, medications and fluid balance. It provides a comprehensive overview of the patient's current condition and medical needs.

    Original Description:

    SBAR form

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    This document contains a patient assessment form with sections for situation, background, assessment, recommendations, and to-do list. The assessment includes vital signs, neurological status, respiratory status, cardiovascular function, gastrointestinal/genitourinary systems, musculoskeletal issues, skin, drains, IV access, immune status, labs, medications and fluid balance. It provides a comprehensive overview of the patient's current condition and medical needs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    75 views7 pages

    Nursing Brains

    Uploaded by

    Michael Kim
    This document contains a patient assessment form with sections for situation, background, assessment, recommendations, and to-do list. The assessment includes vital signs, neurological status, respiratory status, cardiovascular function, gastrointestinal/genitourinary systems, musculoskeletal issues, skin, drains, IV access, immune status, labs, medications and fluid balance. It provides a comprehensive overview of the patient's current condition and medical needs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 7
    At a glance
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    The document appears to be a template for documenting important medical information for patients such as vital signs, lab results, treatments, and care plan.

    The document tracks information about a patient's identification, medical history, assessments, lab results, vital signs, medications, procedures, diet, elimination, wounds/drains, activity levels, and more.

    The document documents information about a patient's respiratory status, cardiovascular status, gastrointestinal status, skin, neurological status, musculoskeletal status, safety concerns, isolation precautions, and more.

    Room #: Code: MD:

    Dx: Allergies:

    SITUATION Safety: ❑ Confused ❑ Fall ❑ Restraints ❑ Alarm ❑ Suicide BACKGROUND


    Isolation: ❑ None ❑ Contact ❑ Droplet ❑ Airborne ❑ Neutropenic
    Admit Date: ______ From: ______ Reason: _____________________ Tests Done PMH: Psychosocial:
    Hospital Course:

    Decision Maker:

    ASSESSMENT
    Temperature Neuro: 4 3 2 1 ❑ EVD Cardiac Hemodynamics ❑ A-Line
    NOC T-Max _____ Day T-Max _____ EF: ______ Echo Date: _____________ ❑ CVP Monitor
    RASS _______ CAM +- ❑ Swann
    Rhythm: _________________________
    Pain

    GCS _____________________________
    Respiratory ❑ Clear Vent Settings ❑ RT GI GU
    ❑ ET ❑ ARDS ❑ NG ❑ OG ❑ PEG ❑ LWS ______ ❑ Foley ❑ BSC ❑ BRP ❑ Anuric ❑ Dialysis
    ❑ Trach C-Diff: - + Last BM: _________
    ❑ Ch T MODE ________ FiO2 ____________ NOCS DAYS
    ❑ IS In ______ Out______ In ______ Out ______
    PS ___________ PEEP ___________ In ______ Out ______ In ______ Out ______
    In ______ Out ______ In ______ Out ______
    Vt ____________ RATE ____________ Diet
    Fluid Balance
    P/F Ratio: _____

    Muskuloskeletal Skin Drains IV Sites


    ❑ Clear ❑ Dsng: _________________ ❑ PIV:
    ❑ Wounds: ______________________
    ❑ Central:

    ❑ PICC:
    ❑ SCDs ❑ TEDs DVT & Stress Ulcer Prophylaxis: Immune System
    ❑ Boots ❑ Special Bed ❑ Heparin ❑ Lovenox ❑ SCDs Flu: ❑ Needs ❑ Received ❑ Other:
    ❑ Sling ❑ Ambulating ❑ Pepcid ❑ Protonix PNA: ❑ Needs ❑ Received
    MRSA: ❑ Admit ❑ > 7 Days in ICU
    Gtts Sepsis: ❑ Infection ❑ Simple ❑ Severe Lab Draws ❑ K Parameters
    1) ___________________ @ ________ Lactate: __________ CVP: _______ ScVO2: ________ ❑ Mg
    2) ___________________ @ ________ ❑ Ph
    ❑ Abx: _____________________ Given @ :_________ ❑ Ca
    3) ___________________ @ ________
    ❑ Abx: _____________________ Given @: _________ PRNs Given
    4) ___________________ @ ________
    5) ___________________ @ ________ ❑ Abx: _____________________ Given @: _________
    6) ___________________ @ ________ ❑ Abx: _____________________ Given @:_________ Accu-Check:
    7) ___________________ @ ________ Cultures: ❑ Blood x2 ❑ Urine ❑ Sputum
    RECOMMENDATION / PT NEEDS TO-DO LIST Na: _____ ______ ______ K: _____ ______ ______
    Mg: _____ ______ ______ Ca: _____ ______ ______
    Ph: _____ ______ ______ Cr: _____ ______ ______
    BUN: _____ ______ ______ WBC: _____ ______ ______
    Hgb: _____ ______ ______ PLT: _____ ______ ______
    PT: _____ ______ ______ INR: _____ ______ ______
    Lactate: _____ ______ ______ HCO3: _____ ______ ______
    Other:
    MISC
    Room #: Code: MD:
    Dx: Allergies:

    SITUATION Safety: ❑ Confused ❑ Fall ❑ Restraints ❑ Alarm ❑ Suicide BACKGROUND


    Isolation: ❑ None ❑ Contact ❑ Droplet ❑ Airborne ❑ Neutropenic
    Admit Date: ______ From: ______ Reason: _____________________ Tests Done PMH: Psychosocial:
    Hospital Course:

    Decision Maker:

    ASSESSMENT
    Temperature Neuro: 4 3 2 1 ❑ EVD Cardiac Hemodynamics ❑ A-Line
    NOC T-Max _____ Day T-Max _____ EF: ______ Echo Date: _____________ ❑ CVP Monitor
    RASS _______ CAM +- ❑ Swann
    Rhythm: _________________________
    Pain

    GCS _____________________________

    Respiratory ❑ Clear Vent Settings ❑ RT GI GU


    ❑ ET ❑ ARDS ❑ NG ❑ OG ❑ PEG ❑ LWS ______ ❑ Foley ❑ BSC ❑ BRP ❑ Anuric ❑ Dialysis
    ❑ Trach C-Diff: - + Last BM: _________
    ❑ Ch T MODE ________ FiO2 ____________ NOCS DAYS
    ❑ IS In ______ Out______ In ______ Out ______
    PS ___________ PEEP ___________ In ______ Out ______ In ______ Out ______
    In ______ Out ______ In ______ Out ______
    Vt ____________ RATE ____________ Diet
    Fluid Balance
    P/F Ratio: _____

    Muskuloskeletal Skin Drains IV Sites


    ❑ Clear ❑ Dsng: _________________ ❑ PIV:
    ❑ Wounds: ______________________
    ❑ Central:

    ❑ PICC:
    ❑ SCDs ❑ TEDs DVT & Stress Ulcer Prophylaxis: Immune System
    ❑ Boots ❑ Special Bed ❑ Heparin ❑ Lovenox ❑ SCDs Flu: ❑ Needs ❑ Received ❑ Other:
    ❑ Sling ❑ Ambulating ❑ Pepcid ❑ Protonix PNA: ❑ Needs ❑ Received
    MRSA: ❑ Admit ❑ > 7 Days in ICU
    Gtts Sepsis: ❑ Infection ❑ Simple ❑ Severe Lab Draws ❑ K Parameters
    1) ___________________ @ ________ Lactate: __________ CVP: _______ ScVO2: ________ ❑ Mg
    2) ___________________ @ ________ ❑ Ph
    ❑ Abx: _____________________ Given @ :_________ ❑ Ca
    3) ___________________ @ ________
    ❑ Abx: _____________________ Given @: _________ PRNs Given
    4) ___________________ @ ________
    5) ___________________ @ ________ ❑ Abx: _____________________ Given @: _________
    6) ___________________ @ ________ ❑ Abx: _____________________ Given @:_________ Accu-Check:
    7) ___________________ @ ________ Cultures: ❑ Blood x2 ❑ Urine ❑ Sputum
    RECOMMENDATION / PT NEEDS TO-DO LIST Na: _____ ______ ______ K: _____ ______ ______
    Mg: _____ ______ ______ Ca: _____ ______ ______
    Ph: _____ ______ ______ Cr: _____ ______ ______
    BUN: _____ ______ ______ WBC: _____ ______ ______
    Hgb: _____ ______ ______ PLT: _____ ______ ______
    PT: _____ ______ ______ INR: _____ ______ ______
    Lactate: _____ ______ ______ HCO3: _____ ______ ______
    Other:
    MISC
    Room #: Code: MD:
    Dx: Allergies:

    SITUATION Safety: ❑ Confused ❑ Fall ❑ Restraints ❑ Alarm ❑ Suicide BACKGROUND


    Isolation: ❑ None ❑ Contact ❑ Droplet ❑ Airborne ❑ Neutropenic
    Admit Date: ______ From: ______ Reason: _____________________ Tests Done PMH: Psychosocial:
    Hospital Course:

    Decision Maker:

    ASSESSMENT
    Temperature Neuro: 4 3 2 1 ❑ EVD Cardiac Hemodynamics ❑ A-Line
    NOC T-Max _____ Day T-Max _____ EF: ______ Echo Date: _____________ ❑ CVP Monitor
    RASS _______ CAM +- ❑ Swann
    Rhythm: _________________________
    Pain

    GCS _____________________________
    Respiratory ❑ Clear Vent Settings ❑ RT GI GU
    ❑ ET ❑ ARDS ❑ NG ❑ OG ❑ PEG ❑ LWS ______ ❑ Foley ❑ BSC ❑ BRP ❑ Anuric ❑ Dialysis
    ❑ Trach C-Diff: - + Last BM: _________
    ❑ Ch T MODE ________ FiO2 ____________ NOCS DAYS
    ❑ IS In ______ Out______ In ______ Out ______
    PS ___________ PEEP ___________ In ______ Out ______ In ______ Out ______
    In ______ Out ______ In ______ Out ______
    Vt ____________ RATE ____________ Diet
    Fluid Balance
    P/F Ratio: _____

    Muskuloskeletal Skin Drains IV Sites


    ❑ Clear ❑ Dsng: _________________ ❑ PIV:
    ❑ Wounds: ______________________
    ❑ Central:

    ❑ PICC:
    ❑ SCDs ❑ TEDs DVT & Stress Ulcer Prophylaxis: Immune System
    ❑ Boots ❑ Special Bed ❑ Heparin ❑ Lovenox ❑ SCDs Flu: ❑ Needs ❑ Received ❑ Other:
    ❑ Sling ❑ Ambulating ❑ Pepcid ❑ Protonix PNA: ❑ Needs ❑ Received
    MRSA: ❑ Admit ❑ > 7 Days in ICU
    Gtts Sepsis: ❑ Infection ❑ Simple ❑ Severe Lab Draws ❑ K Parameters
    1) ___________________ @ ________ Lactate: __________ CVP: _______ ScVO2: ________ ❑ Mg
    2) ___________________ @ ________ ❑ Ph
    ❑ Abx: _____________________ Given @ :_________ ❑ Ca
    3) ___________________ @ ________
    ❑ Abx: _____________________ Given @: _________ PRNs Given
    4) ___________________ @ ________
    5) ___________________ @ ________ ❑ Abx: _____________________ Given @: _________
    6) ___________________ @ ________ ❑ Abx: _____________________ Given @:_________ Accu-Check:
    7) ___________________ @ ________ Cultures: ❑ Blood x2 ❑ Urine ❑ Sputum
    RECOMMENDATION / PT NEEDS TO-DO LIST Na: _____ ______ ______ K: _____ ______ ______
    Mg: _____ ______ ______ Ca: _____ ______ ______
    Ph: _____ ______ ______ Cr: _____ ______ ______
    BUN: _____ ______ ______ WBC: _____ ______ ______
    Hgb: _____ ______ ______ PLT: _____ ______ ______
    PT: _____ ______ ______ INR: _____ ______ ______
    Lactate: _____ ______ ______ HCO3: _____ ______ ______
    Other:
    MISC
    Room #: Code: MD:
    Dx: Allergies:

    SITUATION Safety: ❑ Confused ❑ Fall ❑ Restraints ❑ Alarm ❑ Suicide BACKGROUND


    Isolation: ❑ None ❑ Contact ❑ Droplet ❑ Airborne ❑ Neutropenic
    Admit Date: ______ From: ______ Reason: _____________________ Tests Done PMH: Psychosocial:
    Hospital Course:

    Decision Maker:

    ASSESSMENT
    Temperature Neuro: 4 3 2 1 ❑ EVD Cardiac Hemodynamics ❑ A-Line
    NOC T-Max _____ Day T-Max _____ EF: ______ Echo Date: _____________ ❑ CVP Monitor
    RASS _______ CAM +- ❑ Swann
    Rhythm: _________________________
    Pain

    GCS _____________________________
    Respiratory ❑ Clear Vent Settings ❑ RT GI GU
    ❑ ET ❑ ARDS ❑ NG ❑ OG ❑ PEG ❑ LWS ______ ❑ Foley ❑ BSC ❑ BRP ❑ Anuric ❑ Dialysis
    ❑ Trach C-Diff: - + Last BM: _________
    ❑ Ch T MODE ________ FiO2 ____________ NOCS DAYS
    ❑ IS In ______ Out______ In ______ Out ______
    PS ___________ PEEP ___________ In ______ Out ______ In ______ Out ______
    In ______ Out ______ In ______ Out ______
    Vt ____________ RATE ____________ Diet
    Fluid Balance
    P/F Ratio: _____

    Muskuloskeletal Skin Drains IV Sites


    ❑ Clear ❑ Dsng: _________________ ❑ PIV:
    ❑ Wounds: ______________________
    ❑ Central:

    ❑ PICC:
    ❑ SCDs ❑ TEDs DVT & Stress Ulcer Prophylaxis: Immune System
    ❑ Boots ❑ Special Bed ❑ Heparin ❑ Lovenox ❑ SCDs Flu: ❑ Needs ❑ Received ❑ Other:
    ❑ Sling ❑ Ambulating ❑ Pepcid ❑ Protonix PNA: ❑ Needs ❑ Received
    MRSA: ❑ Admit ❑ > 7 Days in ICU
    Gtts Sepsis: ❑ Infection ❑ Simple ❑ Severe Lab Draws ❑ K Parameters
    1) ___________________ @ ________ Lactate: __________ CVP: _______ ScVO2: ________ ❑ Mg
    2) ___________________ @ ________ ❑ Ph
    ❑ Abx: _____________________ Given @ :_________ ❑ Ca
    3) ___________________ @ ________
    ❑ Abx: _____________________ Given @: _________ PRNs Given
    4) ___________________ @ ________
    5) ___________________ @ ________ ❑ Abx: _____________________ Given @: _________
    6) ___________________ @ ________ ❑ Abx: _____________________ Given @:_________ Accu-Check:
    7) ___________________ @ ________ Cultures: ❑ Blood x2 ❑ Urine ❑ Sputum
    RECOMMENDATION / PT NEEDS TO-DO LIST Na: _____ ______ ______ K: _____ ______ ______
    Mg: _____ ______ ______ Ca: _____ ______ ______
    Ph: _____ ______ ______ Cr: _____ ______ ______
    BUN: _____ ______ ______ WBC: _____ ______ ______
    Hgb: _____ ______ ______ PLT: _____ ______ ______
    PT: _____ ______ ______ INR: _____ ______ ______
    Lactate: _____ ______ ______ HCO3: _____ ______ ______
    Other:
    MISC
    Room #: Code: MD:
    Dx: Allergies:

    SITUATION Safety: ❑ Confused ❑ Fall ❑ Restraints ❑ Alarm ❑ Suicide BACKGROUND


    Isolation: ❑ None ❑ Contact ❑ Droplet ❑ Airborne ❑ Neutropenic
    Admit Date: ______ From: ______ Reason: _____________________ Tests Done PMH: Psychosocial:
    Hospital Course:

    Decision Maker:

    ASSESSMENT
    Temperature Neuro: 4 3 2 1 ❑ EVD Cardiac Hemodynamics ❑ A-Line
    NOC T-Max _____ Day T-Max _____ EF: ______ Echo Date: _____________ ❑ CVP Monitor
    RASS _______ CAM +- ❑ Swann
    Rhythm: _________________________
    Pain

    GCS _____________________________
    Respiratory ❑ Clear Vent Settings ❑ RT GI GU
    ❑ ET ❑ ARDS ❑ NG ❑ OG ❑ PEG ❑ LWS ______ ❑ Foley ❑ BSC ❑ BRP ❑ Anuric ❑ Dialysis
    ❑ Trach C-Diff: - + Last BM: _________
    ❑ Ch T MODE ________ FiO2 ____________ NOCS DAYS
    ❑ IS In ______ Out______ In ______ Out ______
    PS ___________ PEEP ___________ In ______ Out ______ In ______ Out ______
    In ______ Out ______ In ______ Out ______
    Vt ____________ RATE ____________ Diet
    Fluid Balance
    P/F Ratio: _____

    Muskuloskeletal Skin Drains IV Sites


    ❑ Clear ❑ Dsng: _________________ ❑ PIV:
    ❑ Wounds: ______________________
    ❑ Central:

    ❑ PICC:
    ❑ SCDs ❑ TEDs DVT & Stress Ulcer Prophylaxis: Immune System
    ❑ Boots ❑ Special Bed ❑ Heparin ❑ Lovenox ❑ SCDs Flu: ❑ Needs ❑ Received ❑ Other:
    ❑ Sling ❑ Ambulating ❑ Pepcid ❑ Protonix PNA: ❑ Needs ❑ Received
    MRSA: ❑ Admit ❑ > 7 Days in ICU
    Gtts Sepsis: ❑ Infection ❑ Simple ❑ Severe Lab Draws ❑ K Parameters
    1) ___________________ @ ________ Lactate: __________ CVP: _______ ScVO2: ________ ❑ Mg
    2) ___________________ @ ________ ❑ Ph
    ❑ Abx: _____________________ Given @ :_________ ❑ Ca
    3) ___________________ @ ________
    ❑ Abx: _____________________ Given @: _________ PRNs Given
    4) ___________________ @ ________
    5) ___________________ @ ________ ❑ Abx: _____________________ Given @: _________
    6) ___________________ @ ________ ❑ Abx: _____________________ Given @:_________ Accu-Check:
    7) ___________________ @ ________ Cultures: ❑ Blood x2 ❑ Urine ❑ Sputum
    RECOMMENDATION / PT NEEDS TO-DO LIST Na: _____ ______ ______ K: _____ ______ ______
    Mg: _____ ______ ______ Ca: _____ ______ ______
    Ph: _____ ______ ______ Cr: _____ ______ ______
    BUN: _____ ______ ______ WBC: _____ ______ ______
    Hgb: _____ ______ ______ PLT: _____ ______ ______
    PT: _____ ______ ______ INR: _____ ______ ______
    Lactate: _____ ______ ______ HCO3: _____ ______ ______
    Other:
    MISC
    Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____ Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____

    Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________ Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________
    PMH Background Plan PMH Background Plan

    Neuro 4 3 2 1 Cardiac EF: ______ Resp GI NG/GT/JT Neuro 4 3 2 1 Cardiac EF: ______ Resp GI NG/GT/JT
    DW: ______ Sat ____% on _______ Last BM: DW: ______ Sat ____% on _______ Last BM:
    Tx Diet: Tx Diet:

    GU IV Sites IV Fluids Skin GU IV Sites IV Fluids Skin


    Amber Void _________ on _______ Amber Void _________ on _______
    Yellow Foley Yellow Foley
    Straw BSC _________ on _______ Straw BSC _________ on _______
    Clr/Cldy Inct Dsng ! Clr/Cldy Inct Dsng !
    Odor UTI Odor UTI
    ! site / tubing ! site / tubing

    Drains/Tubes Accu ! AC HS Time Tmp HR RR O2 BP Pain Drains/Tubes Accu ! AC HS Time Tmp HR RR O2 BP Pain
    _______ @ _______ _______ @ _______
    _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
    _______ @ _______ _______ @ _______
    _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
    _______ @ _______ _______ @ _______
    Draws Draws
    _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
    Previous PRNs Previous PRNs
    _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
    _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____

    Intake & Output PRNs given Precautions: F Bld ASP Sz Cont Air Drop Intake & Output PRNs given Precautions: F Bld ASP Sz Cont Air Drop
    PS: / _________ @ _______ Activity: Ad lib Br ___º BRP AMB OOB/Ch PS: / _________ @ _______ Activity: Ad lib Br ___º BRP AMB OOB/Ch
    + / - _____ @ _______ _________ @ _______ Allergies: NKDA __________________________ + / - _____ @ _______ _________ @ _______ Allergies: NKDA __________________________
    + / - _____ @ _______ + / - _____ @ _______
    _________ @ _______ WBC ____ PT _____ K ____, _____ _________ @ _______ WBC ____ PT _____ K ____, _____
    + / - _____ @ _______ + / - _____ @ _______
    _________ @ _______ Hgb _____ INR ____ Mg ____ _________ @ _______ Hgb _____ INR ____ Mg ____
    + / - _____ @ _______ + / - _____ @ _______
    + / - _____ @ _______ _________ @ _______ Hct _____ BUN ____ Trop ____, ___, ____ + / - _____ @ _______ _________ @ _______ Hct _____ BUN ____ Trop ____, ___, ____
    IN: _____ Out: _____ PLT ____ Cr _____ IN: _____ Out: _____ PLT ____ Cr _____
    To Do: To Do:
    Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____ Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____

    Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________ Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________
    PMH Background Plan PMH Background Plan

    Neuro 4 3 2 1 Cardiac EF: ______ Resp GI NG/GT/JT Neuro 4 3 2 1 Cardiac EF: ______ Resp GI NG/GT/JT
    DW: ______ Sat ____% on _______ Last BM: DW: ______ Sat ____% on _______ Last BM:
    Tx Diet: Tx Diet:

    GU IV Sites IV Fluids Skin GU IV Sites IV Fluids Skin


    Amber Void _________ on _______ Amber Void _________ on _______
    Yellow Foley Yellow Foley
    Straw BSC _________ on _______ Straw BSC _________ on _______
    Clr/Cldy Inct Dsng ! Clr/Cldy Inct Dsng !
    Odor UTI Odor UTI
    ! site / tubing ! site / tubing

    Drains/Tubes Accu ! AC HS Time Tmp HR RR O2 BP Pain Drains/Tubes Accu ! AC HS Time Tmp HR RR O2 BP Pain
    _______ @ _______ _______ @ _______
    _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
    _______ @ _______ _______ @ _______
    _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
    _______ @ _______ _______ @ _______
    Draws Draws
    _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
    Previous PRNs Previous PRNs
    _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____
    _____ _____ _____ _____ _____ ______ _____ _____ _____ _____ _____ _____ ______ _____

    Intake & Output PRNs given Precautions: F Bld ASP Sz Cont Air Drop Intake & Output PRNs given Precautions: F Bld ASP Sz Cont Air Drop
    PS: / _________ @ _______ Activity: Ad lib Br ___º BRP AMB OOB/Ch PS: / _________ @ _______ Activity: Ad lib Br ___º BRP AMB OOB/Ch
    + / - _____ @ _______ _________ @ _______ Allergies: NKDA __________________________ + / - _____ @ _______ _________ @ _______ Allergies: NKDA __________________________
    + / - _____ @ _______ + / - _____ @ _______
    _________ @ _______ WBC ____ PT _____ K ____, _____ _________ @ _______ WBC ____ PT _____ K ____, _____
    + / - _____ @ _______ + / - _____ @ _______
    _________ @ _______ Hgb _____ INR ____ Mg ____ _________ @ _______ Hgb _____ INR ____ Mg ____
    + / - _____ @ _______ + / - _____ @ _______
    + / - _____ @ _______ _________ @ _______ Hct _____ BUN ____ Trop ____, ___, ____ + / - _____ @ _______ _________ @ _______ Hct _____ BUN ____ Trop ____, ___, ____
    IN: _____ Out: _____ PLT ____ Cr _____ IN: _____ Out: _____ PLT ____ Cr _____
    To Do: To Do:

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