Drugs/Fluids Administered Name:___ Last 4: Date: Time: Weight:_ lbs kg Height:_ Blood Type_.

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Presentation transcript:

Drugs/Fluids Administered Name:_________ Last 4:________ Date:____________ Time:__________ Weight:_______ lbs ______kg Height:_________ Blood Type_____ TQ Time On: TQ Converted: Drugs/Fluids Administered Allergies: M.I.S.T. REPORT MOI: Injuries: Stable / Unstable Treatments: Problem 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Plans Drug Dose Time Route Loc Call script: “THIS IS _______________________________, (JOB/POSITION):________________________________. I HAVE A PATIENT WITH _______________________ WHO I THINK HAS ______________________, AND I NEED____________________________________________________________________________.” CHIEF COMPLAINT:_____________________________________________________________________ BRIEF HISTORY:________________________________________________________________________ PE: VITALS: HR:____________________________ BLOOD PRESSURE: _________________________ RESPIRATION RATE: ______________________ OXYGEN SATURATION: _______________________ TEMPERATURE: ____________________ MENTAL STATUS (AVPU): ___________________________ BRIEF EXAM: ___________________________________________________________________________ ________________________________________________________________________________________. “I NEED _______________.” (CONSULTATION, HELP, ADVICE, TRANSPO…) TeleMed Recommendations: 1. 2. 3. 4. Standing Orders: Vitals Every____________ Normal Ranges Turn Every_____________ Systolic BP:_____________ IV Fluids________________ Diastolic BP:_____________ GCS Every_______________ Mean Arterial Pressure(MAP):_____________ Measure Urine___________ Urine Output:_____________ Vent Settings:____________ Heart rate(HR):_____________ Other:__________________ End Tidal CO2(ETCO2):______________ SpO2:______________ Trend Vitals:, Norms? UOP? GCS Tube Care: Open? Clean? Sites? Pulmonary Status:Airway open? Lung sounds? Suction? Hydration Status: UOP, intake vs output? Wounds and Dressings: Drainage? Redness? Swelling? Smell? Splints: CHECK PERIPHERAL PULSES Bowel Care: Last BM? Diarrhea? Impacted? Bladder Care: Last voiding? Swollen? Catheter clean/patent Eye Care: Contact Lenses? Drops? Ointment? Mouth Care: Loose Teeth, Dry Mucus Membranes, Oral Care q4 Mobility: Passive exercises? Calf Massage for DVT Prophylaxis Skin Care: Pressure sores forming? Skin Dry? Buttocks/Groin?