3. 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:
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?