"Telemetry Brain Sheet Templates - Four Patients"

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Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____
Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____
Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________
Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________
PMH
Background
Plan
PMH
Background
Plan
Resp
Resp
Neuro
4 3 2 1 Cardiac
EF: ______
GI
NG/GT/JT
Neuro
4 3 2 1 Cardiac
EF: ______
GI
NG/GT/JT
DW: ______
Sat ____% on _______
DW: ______
Sat ____% on _______
Last BM:
Last BM:
Tx
Tx
Diet:
Diet:
GU
IV Sites
IV Fluids
Skin
GU
IV Sites
IV Fluids
Skin
Amber
Void
Amber
Void
_________ on _______
_________ on _______
Yellow
Foley
Yellow
Foley
_________ on _______
_________ on _______
Straw
BSC
Straw
BSC
Clr/Cldy
Inct
Dsng !
Clr/Cldy
Inct
Dsng !
Odor
UTI
Odor
UTI
! site / tubing
! site / tubing
Drains/Tubes
Drains/Tubes
Accu ! AC HS
Time
Tmp
HR
RR
O2
BP
Pain
Accu ! AC HS
Time
Tmp
HR
RR
O2
BP
Pain
_______ @ _______
_______ @ _______
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
_______ @ _______
_______ @ _______
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
_______ @ _______
_______ @ _______
Draws
Draws
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
Previous PRNs
Previous PRNs
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
Intake & Output
PRNs given
Intake & Output
PRNs given
Precautions: F Bld ASP Sz Cont Air Drop
Precautions: F Bld ASP Sz Cont Air Drop
_________ @ _______
_________ @ _______
PS:
/
PS:
/
Activity: Ad lib Br ___º BRP AMB OOB/Ch
Activity: Ad lib Br ___º BRP AMB OOB/Ch
+ / - _____ @ _______
+ / - _____ @ _______
_________ @ _______
_________ @ _______
Allergies: NKDA __________________________
Allergies: NKDA __________________________
+ / - _____ @ _______
+ / - _____ @ _______
_________ @ _______
_________ @ _______
WBC ____ PT _____ K ____, _____
WBC ____ PT _____ K ____, _____
WBC ____ PT _____ K ____, _____
+ / - _____ @ _______
+ / - _____ @ _______
_________ @ _______
_________ @ _______
Hgb _____ INR ____ Mg ____
Hgb _____ INR ____ Mg ____
Hgb _____ INR ____ Mg ____
+ / - _____ @ _______
+ / - _____ @ _______
_________ @ _______
_________ @ _______
Hct _____ BUN ____ Trop ____, ___, ____
Hct _____ BUN ____ Trop ____, ___, ____
Hct _____ BUN ____ Trop ____, ___, ____
+ / - _____ @ _______
+ / - _____ @ _______
IN: _____ Out: _____
IN: _____ Out: _____
PLT ____
PLT ____
Cr _____
Cr _____
PLT ____
Cr _____
To Do:
To Do:
Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____
Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____
Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________
Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________
PMH
Background
Plan
PMH
Background
Plan
Resp
Resp
Neuro
4 3 2 1 Cardiac
EF: ______
GI
NG/GT/JT
Neuro
4 3 2 1 Cardiac
EF: ______
GI
NG/GT/JT
DW: ______
Sat ____% on _______
DW: ______
Sat ____% on _______
Last BM:
Last BM:
Tx
Tx
Diet:
Diet:
GU
IV Sites
IV Fluids
Skin
GU
IV Sites
IV Fluids
Skin
Amber
Void
Amber
Void
_________ on _______
_________ on _______
Yellow
Foley
Yellow
Foley
_________ on _______
_________ on _______
Straw
BSC
Straw
BSC
Clr/Cldy
Inct
Dsng !
Clr/Cldy
Inct
Dsng !
Odor
UTI
Odor
UTI
! site / tubing
! site / tubing
Drains/Tubes
Drains/Tubes
Accu ! AC HS
Time
Tmp
HR
RR
O2
BP
Pain
Accu ! AC HS
Time
Tmp
HR
RR
O2
BP
Pain
_______ @ _______
_______ @ _______
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
_______ @ _______
_______ @ _______
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
_______ @ _______
_______ @ _______
Draws
Draws
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
Previous PRNs
Previous PRNs
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
Intake & Output
PRNs given
Intake & Output
PRNs given
Precautions: F Bld ASP Sz Cont Air Drop
Precautions: F Bld ASP Sz Cont Air Drop
_________ @ _______
_________ @ _______
PS:
/
PS:
/
Activity: Ad lib Br ___º BRP AMB OOB/Ch
Activity: Ad lib Br ___º BRP AMB OOB/Ch
+ / - _____ @ _______
+ / - _____ @ _______
_________ @ _______
_________ @ _______
Allergies: NKDA __________________________
Allergies: NKDA __________________________
+ / - _____ @ _______
+ / - _____ @ _______
_________ @ _______
_________ @ _______
WBC ____ PT _____ K ____, _____
WBC ____ PT _____ K ____, _____
WBC ____ PT _____ K ____, _____
+ / - _____ @ _______
+ / - _____ @ _______
_________ @ _______
_________ @ _______
Hgb _____ INR ____ Mg ____
Hgb _____ INR ____ Mg ____
Hgb _____ INR ____ Mg ____
+ / - _____ @ _______
+ / - _____ @ _______
_________ @ _______
_________ @ _______
Hct _____ BUN ____ Trop ____, ___, ____
Hct _____ BUN ____ Trop ____, ___, ____
Hct _____ BUN ____ Trop ____, ___, ____
+ / - _____ @ _______
+ / - _____ @ _______
IN: _____ Out: _____
IN: _____ Out: _____
PLT ____
PLT ____
Cr _____
Cr _____
PLT ____
Cr _____
To Do:
To Do:
Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____
Pt: _________________ M/F Age: _____Admit Date: __________MD: ______________ Rm # _____
Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________
Dx: ________________ Surg/Proc: ____________ POD #:_____ Code: _____ Rhythm: ___________
PMH
Background
Plan
PMH
Background
Plan
Resp
Resp
Neuro
4 3 2 1 Cardiac
EF: ______
GI
NG/GT/JT
Neuro
4 3 2 1 Cardiac
EF: ______
GI
NG/GT/JT
DW: ______
Sat ____% on _______
DW: ______
Sat ____% on _______
Last BM:
Last BM:
Tx
Tx
Diet:
Diet:
GU
IV Sites
IV Fluids
Skin
GU
IV Sites
IV Fluids
Skin
Amber
Void
Amber
Void
_________ on _______
_________ on _______
Yellow
Foley
Yellow
Foley
_________ on _______
_________ on _______
Straw
BSC
Straw
BSC
Clr/Cldy
Inct
Dsng !
Clr/Cldy
Inct
Dsng !
Odor
UTI
Odor
UTI
! site / tubing
! site / tubing
Drains/Tubes
Drains/Tubes
Accu ! AC HS
Time
Tmp
HR
RR
O2
BP
Pain
Accu ! AC HS
Time
Tmp
HR
RR
O2
BP
Pain
_______ @ _______
_______ @ _______
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
_______ @ _______
_______ @ _______
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
_______ @ _______
_______ @ _______
Draws
Draws
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
Previous PRNs
Previous PRNs
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
_____ _____ _____ _____ _____ ______ _____
Intake & Output
PRNs given
Intake & Output
PRNs given
Precautions: F Bld ASP Sz Cont Air Drop
Precautions: F Bld ASP Sz Cont Air Drop
_________ @ _______
_________ @ _______
PS:
/
PS:
/
Activity: Ad lib Br ___º BRP AMB OOB/Ch
Activity: Ad lib Br ___º BRP AMB OOB/Ch
+ / - _____ @ _______
+ / - _____ @ _______
_________ @ _______
_________ @ _______
Allergies: NKDA __________________________
Allergies: NKDA __________________________
+ / - _____ @ _______
+ / - _____ @ _______
_________ @ _______
_________ @ _______
WBC ____ PT _____ K ____, _____
WBC ____ PT _____ K ____, _____
+ / - _____ @ _______
+ / - _____ @ _______
_________ @ _______
_________ @ _______
Hgb _____ INR ____ Mg ____
Hgb _____ INR ____ Mg ____
+ / - _____ @ _______
+ / - _____ @ _______
_________ @ _______
_________ @ _______
Hct _____ BUN ____ Trop ____, ___, ____
Hct _____ BUN ____ Trop ____, ___, ____
+ / - _____ @ _______
+ / - _____ @ _______
IN: _____ Out: _____
IN: _____ Out: _____
PLT ____
Cr _____
PLT ____
Cr _____
To Do:
To Do:
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