“Brain”

Rm#

Pt.

Diagnosis

(Hx)
Doctor

Allergies

Diet

BS ac/hs

Activity

IV location IV CVC HL IV CVC HL IV CVC HL IV CVC HL IV CVC HL IV CVC HL

Fluids/rate

Labs
I&O

Vital signs T– T– T– T– T– T–
P– P– P– P– P– P–
RR – RR – RR – RR – RR – RR –
BP – BP – BP – BP – BP – BP –
O2 – O2 – O2 – O2 – O2 – O2 –

MEDS 07 08 09 10 11 12
13 14 15 16 17 18
19
Check BOS/VS/AS/MED BOS/VS/AS/MED/ BOS/VS/AS/MED/ BOS/VS/AS/MED/ BOS/VS/AS/MED/ BOS/VS/AS/MED/
/NOTE/I&O/EOS NOTE/I&O/EOS NOTE/I&O/EOS NOTE/I&O/EOS NOTE/I&O/EOS NOTE/I&O/EOS
List

Notes: