This document contains a patient's medical information including their primary and secondary diagnoses, allergies, code status, anesthesia details, mobility status, IV and catheter status, diet, pain management plan, vital signs, assessments to perform including chest, abdominal, neurological and more. It also lists the patient's medications, laboratory results, and focus of care. Finally, it outlines tasks to complete including assessments, basic care, vitals, glucose checks, and documentation as well as information to check such as medical records, code sheets, and last doctor's orders.

1. Patient:
POD:
Diagnosis
A. Primary:
B. Secondary:
Allergies:
Code Status:
Anesthesia:
Mobility:
IVF:
Catheter:
DIET:
PAIN PCA:
Time:
BP
PR
RR
TEMP
O2 SAT
OTHER CONCERNS:
Medications:
Laboratory Results:
Focus:
Headto Toe assessment
Chestassessment
Abdominal Assessment
DVT
Peripheral VascularAssessment
NeuroVascularAssessment
GlasgowComaScale I&O
Thingsto do onfield:
1. Assessment
2. Basic care – dressing,charting,positioning,mouthcare
3. V/S
4. Glucometer
5. IN’sand OUT’s
Thingsto check:
Blue Book – Kardex,MAR(PCA,epidural,PRN meds),Nrsgflowsheet
RedBook – code sheet,signature sheet,admreportprimaryand
secondary,allergies,interdisciplinarynotes
Last Doctor’s Order: