MED - SURG KARDEX - Hospital Forms

[Pages:4]MED - SURG KARDEX

CODE STATUS DIET TYPE:

FEED

ASSIST

SELF

- - - - - - - - -

- - - - - - - - - - - - - - FLUID

TUBE FEEDING:

RESTRICTION

ADVANCE DIRECTIVE

YES

D _________ E _________

NO

N _________

VITAL SIGNS q4h q8h OTHER

CVP

WEIGHT

PAST MEDICAL HISTORY:

BATH

SPECIAL NOTICE:

COMPLETE ASSIST SELF TUB

SHOWER

OXYGEN

INTAKE / OUTPUT

YES

NO

DRAINS:

FOLEY

NGT

SUCTION

JP

CT HEMOVAC GT OSTOMY OTHER

SUCTION

ACTIVITY

BEDREST BRP OOB CHAIR AMBULATORY

POSITION

------------------

SAFETY FALL PRECAUTIONS SIDE RAILS X 2 SIDE RAILS X 4 RESTRAINTS

POSEY VEST 2 POINT 4 POINT OTHER

ORDER EXP DATE DATE

USUAL MOBILITY BED / CHAIR CONFINED

TRANSFERS WITH ASSIST AMBULATES WITH ASSIST

AMBULATORY ASSISTIVE DEVICE

MENTAL STATUS / BEHAVIOR

TEACHING ALLERGIES

NON TEACHING

8850027 Rev. 05/05

RELIGION

SPECIALTY BED

SOF. CARE MATTRESS

TYPE OF IV: LOCATION: DATE OF INSERTION:

BY: DATE OF DC:

TYPE OF IV: LOCATION: DATE OF INSERTION:

BY: DATE OF DC:

CONDITION

SURGICAL PROCEDURE

PART OF THE MEDICAL RECORD Med Surg Kardex_NURSING

PAGE 1 of 4

DATE ORD.

DAILY TESTS

ACCUCHECKS

DATE

DATE

DONE ORDERED

TREATMENTS

RESPIRATORY THERAPY ORDERS:

OTHER

WOUND CARE / DRESSING CHANGES:

DATE DATE TO ORD. BE DONE

ROUTINE ORDERS & STAT TESTS

PT / OT: SKIN CARE TREATMENTS:

8850027 Rev. 05/05

MISCELLANEOUS:

PART OF THE MEDICAL RECORD

Med Surg Kardex_NURSING

PAGE 2 of 4

DISCHARGE PLANNING

ANTICIPATED DISPOSITION:

HOME

HOME WITH HOME CARE

SPECIFY

NH RETURN

NH PLACEMENT

OTHER

HOME CARE AGENCY CARETAKER / PERSON AVAILABLE p DISCHARGE

PHONE NO

RELATIONSHIP

LEGAL GUARDIAN / NEXT OF KIN HOME PHONE

WORK PHONE

CONSULTS SOCIAL SERVICES HOME CARE DIETARY PT / OT SPEECH GERIATRIC SKIN CARE OTHER:

REASON

Date Requested

Date Done

DATE REQUESTED

D/C ROUNDS - ISSUES FOR FOLLOW UP

INITIALS DATE DONE

COMMUNITY SUPPORT PROGRAM REFERRALS:

PATIENT / FAMILY TEACHING NEEDS:

MEDICATIONS

WOUND CARE

OTHER:

NGT / GT FEEDING

ROOM NAME

8850027 Rev. 05/05

AGE

DIAGNOSIS

PHYSICIAN

SERVICE

PART OF THE MEDICAL RECORD

Med Surg Kardex_NURSING

ADM DATE PAGE 3 of 4

DATE REQUESTED

D/C ROUNDS - ISSUES FOR FOLLOW UP

INITIALS

DATE DONE

8850027 Rev. 05/05

PART OF THE MEDICAL RECORD

Med Surg Kardex_NURSING

PAGE 4 of 4

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