|
Chief Complaints
|
Chief Complaints Comments
|
|
SUBJECTIVE
|
|
|
Respiratory Illness Screening, Fever present
|
|
|
Respiratory Illness Symptoms
• • •
|
Additional Comments
|
|
Travel to a high risk respiratory illness region
|
|
|
Close contact w/ person(s) w/ known communicable illness
|
Additional comments
|
|
Travel/Close contact occur within 14 days of symptom onset
|
|
|
PROCEDURE
|
|
|
Indication (diagnosis)
|
Consent Obtained and signed
|
|
Administered By
|
Site
|
|
START TIME
|
|
|
Technique
|
Technique Comments
|
|
IV access attempts
|
|
|
Catheter Size
|
|
|
Medication/Materials
• • •
|
|
|
NDC
|
Lot#
|
|
Expiration Date
|
|
|
IV Catheter Removed by
|
|
|
Tolerated well
|
Complications
|
|
END TIME
|
|
|
Post procedure instructions
|
Post Procedure Instructions Addt comments
|
|
Follow Up
• • •
|
|
