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Name: Room ID Line: Subjective/Overnight:: Nursing? Patient? PRN Meds? Etc

This document contains fields for collecting a patient's overnight information including vital signs, physical exam findings, lab results, procedures, imaging, consults, and assessment and plan. Key information fields include subjective/overnight notes, intake/output, vital signs, physical exam by body system, common lab tests, oxygen settings, lines/drains, imaging, EKG, procedures, and assessment and plan.

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theintrepiddodger
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1K views

Name: Room ID Line: Subjective/Overnight:: Nursing? Patient? PRN Meds? Etc

This document contains fields for collecting a patient's overnight information including vital signs, physical exam findings, lab results, procedures, imaging, consults, and assessment and plan. Key information fields include subjective/overnight notes, intake/output, vital signs, physical exam by body system, common lab tests, oxygen settings, lines/drains, imaging, EKG, procedures, and assessment and plan.

Uploaded by

theintrepiddodger
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Name: Room

ID line:
Subjective/Overnight: Nursing? Patient? PRN meds? Etc.

Vitals Intake/Output
T Tmax Ins Outs Net
HR
BP
RR
Sats Device/setting:
Ht/Wt/HC:
Physical Exam Labs
General: MCV WBCDiff Cultures/Other:
HEENT:
Heart:
Lungs
Abdomen:
Extremities:
Ca PTT TotProt Alb
O2 settings? Mg PT TotBili DirBili
Lines/drains? Phos INR AST AlkPhos
ALT

Imaging/EKG/Procedures Consults

Assessment & Plan

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