|
Was consent signed?
|
Allergies and medical history reviewed
|
|
Assessment within normal limits
|
Reason for visit
|
|
If here for migraine, describe symptoms
|
|
|
Vital Signs - Pre-Infusion
|
|
|
Blood Pressure
|
Heart Rate
|
|
O2
|
Temperature
|
|
Respirations
|
|
|
NV
|
Pain Level
|
|
Pain Location
|
|
|
Vitamin Drip
|
|
|
IV site
• • •
|
# of attempts
|
|
IV Started by
|
Drip mixed by
|
|
Drip
• • •
|
IV fluid
• • •
|
|
IV Add ons
• • •
|
IV Drip start time
|
|
IM Injection
• • •
|
IM Injection site
• • •
|
|
Complications
• • •
|
Comments
|
|
IM shot administered by
|
|
|
Vital Signs - Post Infusion
|
|
|
Blood Pressure
|
Heart Rate
|
|
O2
|
NV
|
|
Pain Level
|
Pain Location
|
|
Additional comments
|
|
|
Discharge
|
|
|
IV Drip end time
|
IV d/c intact/without infiltration
|
|
Discharge
• • •
|
Notes
|
|
New Switch
|
|
|
Consent form
|
New Free Draw
|
