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Medical History & Physical Finding
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Good Faith Exam?
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Medical History Reviewed?
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Allergies Reviewed?
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Consents Signed?
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Vitamin Formula & Additives
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Type of IV
• • •
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IV bag/push additives
• • •
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For NAD IV, Zofran 4 mg PO given?
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IV Procedure
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Location of IV
• • •
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Gauge of needle used
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# of attempts to start IV
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IV start time:
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IV end time:
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Drip rate:
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Total amount infused:
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IV status:
• • •
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Patient Education
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Patient Education
• • •
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Notes
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Treatment Provider
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