Answer questions instructions is attached

I

INTRODUCE

YOURSELF

YourName: Your Title: Reason for Being There:

Patient:

Age:

History of Current Problem:

Gender:

S

SITUATION

Height/Weight: Allergies:

Code status:

Privacy Code:

Time:

Attending Physician:

Patient Chief Complaint:

Chief Informant: Family History:

B

BACKGROUND

Past Medical History:

Current Medications:

Social History:

A

ASSESSMENT

VITAL SIGNS:

B/P

HR

RR

TEMP

SP02

PAIN

FALLS RISK

Y N

IV Site:

Accu check:

IV Fluids:

ISOLATION

Isolation Precautions:

Y

N

Contact

Air

Droplet

HEENT

RESPIRATORY

CARDIOVASCULAR

NEUROLOGICAL

GI/GU

I & O

MUSCULOSKELETAL

INTEGUMENTARY

LYMPHATIC

ENDOCRINE

PSYCHOLOGICAL FAMILY - SUPPORT

SAFETY

LABS/TEST

Abnormal:

Pending: Ordered

R

REQUEST/

RECOMMENDATION

Hand off report to: From: