Patient Id:

Facility Name:

Facility Name:

Patient Sex:

Date of visit:

Look of patient:

Patient awake:

Patient alert:

Patient lethargy:

Patient sleeping:

Patient able to conversate:

Patient attended rehab:

Vital BP:

Vital HR:

Vital Temp:

Vital Oxygen:

Vital Trending Findings:

Amount of Food Patient ate:

Amount of Fluid Patient Drank:

IVF:

IVF Rate:

IVF Type:

IVF Picc:

IVF Pic:

IVF Mid Line:

Patient Bowel Motion:

Patient Urinate:

Foley Catheter:

Urostomy Tube:

Patient on Oxygen:

Orders in Chart:

Order Verified:

Administration:

Reason Medication Refused:

IV Antibiotics:

Order Reviewed:

New Orders Medication:

Care Plan Updated:

New Care Plan Initiated:

Type of Care Initiated:

Medicare:

Notes Written:

Consults:

New Recommendation Orders:

Pmd Notified Medications:

Orders Carried Out Medications:

Family Notified Medications:

New Misc Docs Reviewed:

Action Taken:

New Order Labs:

Type Labs:

Result Labs:

New Result Labs:

Pmd Notified Labs:

New Orders Labs:

Family Notified Labs:

New Order Radiology:

Resulted Radiology:

Pmd Notified Radiology:

New Orders Radiology:

Family Notified Radiology:

Pneumovax Immunizations:

Influenza Immunizations:

Covid Immunizations:

Provider Notified:

Provider Agrees:

Orders Written:

Carplan Updated:

Protocols Last 24 Hrs:

Changed Drug Regimen:

Same Drug Regimen:

Primary Nurse Notified:

Nurse Manager Notified:

Nursing Super Notified:

Message:

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