NPO? Y N If so, why?________________ Allergies? ________________________

Patients name__________________________________ Age_________ Room #______

Diagnosis__________________________________________________ MD_________

Brief Medical history:

IV Solution________________ @ ______mL per hour. (Units/hr _________ for heparin)

Location & condition of IV site ____________________________ Date started________

O2 @ _______Liters/minute via _________________ O2 sat ____________

(Feeding, suction, other)_________________________________________kcal/hr_____

Type of diet____________________ Dentures? _________ Are they in? _____________

Intake __________________________________________________________________
Output__________________________________________________________________

Last voiding___________ Foley _____Describe urine_______________

Last BM______________ Describe BM__________________________

Activity level_____________________ Do they need assistance with ADLs? _____

Can they ambulate? Self______ Need assist______ Cannot ambulate ______

Any changes in treatments or medications? ________________________________________________________________________________________________________________________________________________ 

Significant Assessment Data ________________________________________________

Significant Lab Values & Treatments _________________________________________

________________________________________________________________________

 Diabetic Blood Glucose Monitoring:

Time__________ BS _____ Time __________ BS _____ Time __________ BS _____

Meds: