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REASON FOR VISIT
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Comments
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LAST INFUSION
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Facility
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HEIGHT
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WEIGHT
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BMI
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PAST MEDICAL HISTORY
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Other Medical Problems
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SURGICAL HISTORY
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Other Surgeries
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ALLERGIES
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ALLERGIES (OTHER)
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MAR REVIEWED
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MEDICATIONS
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SUPPLEMENTS
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MAR
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MAR
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ANCILLARY DATA
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PRE-INFUSION LABS
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Ancillary Data
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Ancillary Data
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Ancillary Data
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Ancillary Data
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Ancillary Data Comments
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REVIEW OF SYSTEMS
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GENERAL
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[-]
• • •
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[+]
• • •
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Comments
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HAIR, SKIN, NAILS
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[-]
• • •
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[+]
• • •
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Comments
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HEENT
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[-]
• • •
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[+]
• • •
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Comments
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NECK
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Neck [-]
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Neck [+]
• • •
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Comments
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CARDIOVASCULAR
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[-]
• • •
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[+]
• • •
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Comments
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HEMATOLOGIC
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[-]
• • •
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[+]
• • •
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Comments
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RESPIRATORY
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[-]
• • •
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[+]
• • •
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Comments
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GI
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[-]
• • •
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[+]
• • •
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Comments
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GU
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[-]
• • •
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[+]
• • •
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Comments
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PERIPHERAL VASCULAR
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[-]
• • •
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[+]
• • •
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Comments
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MSK
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[-]
• • •
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[+]
• • •
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Comments
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NEURO
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[-]
• • •
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[+]
• • •
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Comments
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ENDOCRINE
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[-]
• • •
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[+]
• • •
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Comments
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PSYCH
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[-]
• • •
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[+]
• • •
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Comments
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PHYSICAL EXAM
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GENERAL
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wnl
• • •
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abn
• • •
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General Comments
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HEENT
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wnl
• • •
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abn
• • •
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HEENT Comments
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SKIN
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wnl
• • •
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abn
• • •
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Skin Comments
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NECK
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wnl
• • •
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abn
• • •
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Neck Comments
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CARDIOVASCULAR
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wnl
• • •
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abn
• • •
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Cardiovascular Comments
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RESPIRATORY
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wnl
• • •
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abn
• • •
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Respiratory Comments
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ABDOMEN
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wnl
• • •
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abn
• • •
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Abdomen Comments
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MSK
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wnl
• • •
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abn
• • •
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MSK Comments
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NEURO
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wnl
• • •
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abn
• • •
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Neuro Comments
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PSYCHOLOGICAL
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wnl
• • •
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abn
• • •
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Psychological Comments
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Physical exam
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Physical exam
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ASSESSMENT
• • •
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PLAN
• • •
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Plan Comments
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MD/NP ORDER
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INFUSION COMPLEX
• • •
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BUD/EXPIRATION/LOT#
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FLUID BASE
• • •
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BUD/EXPIRATION/LOT#
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ADD ONS
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POST-IV PUSH: GLUTATHIONE (200 MG/ML) - 5 ML = 1000 MG
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BUD/EXPIRATION/LOT#
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POST-IV PUSH: GLUTATHIONE (200 MG/ML) - 10 ML = 2000 MG
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BUD/EXPIRATION/LOT#
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POST-IV PUSH: GLUTATHIONE (200 MG/ML) - 15 ML = 3000 MG
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BUD/EXPIRATION/LOT#
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ADDITIONAL NUTRIENTS
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BUD/EXPIRATION/LOT#
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RATE OF INFUSION
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1.Additional Nutrient & Dose/mL
• • •
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1. # mL
• • •
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BUD/EXPIRATION/LOT#
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2. Additional Nutrient & Dose/ml
• • •
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2. # mL
• • •
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BUD/EXPIRATION/LOT#
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3. Additional Nutrient & Dose/ml
• • •
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3. # mL
• • •
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BUD/EXPIRATION/LOT#
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4. Additional Nutrient & Dose/ml
• • •
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4. # mL
• • •
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BUD/EXPIRATION/LOT#
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IV PREPARED BY:
• • •
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IV STARTED BY:
• • •
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CATHETER SIZE
• • •
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SITE OF IV
• • •
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# of Attempts
• • •
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IV START TIME
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STARTING BLOOD PRESSURE & HR
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IV STOP TIME
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ENDING BLOOD PRESSURE & HR
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INFUSION NOTE
|
ADDITIONAL INFUSION COMMENTS
|
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FOLLOW-UP
• • •
|
FOLLOW-UP COMMENTS
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CASE DISCUSSED WITH
• • •
|
"CASE DISCUSSED WITH" COMMENTS
|
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GENERAL COMMENTS
|
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