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