Room: ________ Pt Initials: ________ Dx:___________________________________________

Age: ________ Diet: ____________ _________ Activity: ______________________

VS VS IV Blood Glucose
Time: Time: Type:
T: T: Location: Time:
P: P: Rate: BG:
R: R: Type of fluid:
Blood Glucose
BP: BP: Amt in bag at beg. of
Pain: Pain: clinical:
Time:
Pulse Ox: Pulse Ox: Amt in bag at end of
BG:
Weight: Weight: clinical:

Medication Schedule
Time: Meds:

Time: Meds:

Time: Meds:

Time: Meds:

I & O to Be Documented:

Neuro: GI:

Resp: GU:

C/V: Skin:

Bath NOTES
Linen change
Oral care
Dressing change