|
Patient Identity Verified (2 form verified)
• • •
|
|
|
Patient Consent Forms Signed During Visit
• • •
|
Did patient refuse Care?
• • •
|
|
General Appearance-WNL
|
General Appearance-Abnormal
• • •
|
|
General Comments
|
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Neuro Comments
|
|
|
Psychosocial WNL
|
Psychosocial Abnormal
• • •
|
|
Psychosocial Comments
|
|
|
HEENT WNL
|
HEENT Abnormal
• • •
|
|
HEENT Comments
|
|
|
Skin WNL
|
Skin Lesion
|
|
Skin Comments
|
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Cardiovascular Comments
|
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Lungs Comments
|
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
Abdomen Comments
|
|
|
Musculoskeletal WNL
|
MSK Abnormal
• • •
|
|
Musculoskeletal Comments
|
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
Extrem Comments
|
|
|
|
|
|
IV Site Assessment
|
|
|
Iv in place on Admission?
|
|
|
Date Pre admit Iv dressing last changed
|
Next IV dressing change-Due date (7 days)
|
|
IV Site Type -Present on Admission
|
|
|
Current - IV Gauge
|
IV Patency
• • •
|
|
IV Site Location
|
Site Assessment (Surround Skin)
• • •
|
|
IV Site Care
• • •
|
Pre-admission IV site- comments
|
|
Patient Response
• • •
|
|
|
Pre- Medication Administration
|
|
|
Pre-Medications Administered
|
|
|
Pre-Medication #1
|
Pre-Medication #2
|
|
Pre-Medication #3
|
Pre-Medication #4
|
|
Infusion Medication Administration - #1
|
|
|
Infusion Start Time
|
Infusion Stop Time
|
|
Infusion total time
|
IV lumen used for medication administraion
• • •
|
|
Medication Name
|
Dose
|
|
Route
|
Rate
|
|
Diluent
|
Diluent volume
|
|
Diluent Comments
|
Method of Infusion Delivery
|
|
External Pump Details
|
|
|
Was a pump used for medication Administration
|
|
|
Pump Type
|
Pump Mode
|
|
Infusion Frequency
|
Volume to be infused
|
|
Infusion Rate
|
|
|
Equipment Used
|
|
|
Supplies and Equipment used
• • •
|
|
|
Interventions
|
|
|
Nursing Interventions/Teaching
• • •
|
|
|
Goals of Treatment
|
|
|
Treatment Goal
• • •
|
Goal Comments
|
|
Progress toward goal
|
|
|
Lab Collection
|
|
|
Method of Collection
|
IV lumen used for blood collection
• • •
|
|
Pre-draw prep
• • •
|
Post lab draw intervention
• • •
|
|
Post Lab-IV Patency Assessment
• • •
|
|
|
Labs collected by Nurse
• • •
|
Other Labs collected
|
|
Signature
|
|
|
RN Assessment completed by
|
|
|
RN Signature
|
|
