ICU/CCU Multidisciplinary Rounds Full

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

01

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

02

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

03

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

04

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

05

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

06

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

07

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

08

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

09

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

10

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

11

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

12

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

13

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

14

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

15

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

16

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs

17

• Occupied

  Empty

• Diagnosis

  Select Res Fail Code Blue/Cardiac Alert Hypotension Arrhythmias MI Stent CABG CHF COPD Stroke Bleed Dehydration Fluid Overload Electrolyte imbalance DVT/PE PNU Sepsis DKA C. diff Surgical Exploratory Lap Trauma OD

  • Res Fail
  • Code Blue/Cardiac Alert
  • Hypotension
  • Arrhythmias
  • MI
  • Stent
  • CABG
  • CHF
  • COPD
  • Stroke
  • Bleed
  • Dehydration
  • Fluid Overload
  • Electrolyte imbalance
  • DVT/PE
  • PNU
  • Sepsis
  • DKA
  • C. diff
  • Surgical
  • Exploratory Lap
  • Trauma
  • OD

• Isolation Status

  Select Not in appropriate iso Standard Contact Contact Plus Droplet Airborne Protective

  • Not in appropriate iso
  • Standard
  • Contact
  • Contact Plus
  • Droplet
  • Airborne
  • Protective

• Reason for contact Isolation

  Select Active History of MRSA VRE Acinetobacter MDRO CRE Campylobacter MDRO Enterobacteriaceae ESBL E. coli ESBL Klebsiella ESBL Proteus ESBL Pseudomonas MDRO Serratia ESBL

  • Active
  • History of
  • MRSA
  • VRE
  • Acinetobacter MDRO
  • CRE
  • Campylobacter MDRO
  • Enterobacteriaceae ESBL
  • E. coli ESBL
  • Klebsiella ESBL
  • Proteus ESBL
  • Pseudomonas MDRO
  • Serratia ESBL

• Reason for contact plus Isolation

  Select R/O C. diff. C diff. Norovirus

  • R/O C. diff.
  • C diff.
  • Norovirus

• Reason for droplet isolation

  Select R/O Flu Flu

  • R/O Flu
  • Flu

• Reason for airborne isolation

  Select Shingles R/O TB TB Measles

  • Shingles
  • R/O TB
  • TB
  • Measles

• Respiratory Status?

  Select RA NC HighFlow Blender CPAP BiPAP Vent Intubated Trach

  • RA
  • NC
  • HighFlow
  • Blender
  • CPAP
  • BiPAP
  • Vent
  • Intubated
  • Trach

• Mentation Status

  Select A&O x 3 A&O x 2 A&O x 1 Sedated Confused Intermittent Confused Agitated Unresponsive

  • A&O x 3
  • A&O x 2
  • A&O x 1
  • Sedated
  • Confused
  • Intermittent Confused
  • Agitated
  • Unresponsive

• RASS

  Select +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and calm -1 Drowsy (>10 secs to voice) -2 Light Sedation (<10 sec to voice) -3 Moderate Sedation (moves to voice) -4 Deep Sedation (touch) -5 Unarousable (touch)

  • +4 Combative
  • +3 Very Agitated
  • +2 Agitated
  • +1 Restless
  • 0 Alert and calm
  • -1 Drowsy (>10 secs to voice)
  • -2 Light Sedation (<10 sec to voice)
  • -3 Moderate Sedation (moves to voice)
  • -4 Deep Sedation (touch)
  • -5 Unarousable (touch)

• Nutritional status?

  Select NPO Regular Cardiac Diabetic Clear Liquids Full liquids Dysphasia Diet TF TPN PPN

  • NPO
  • Regular
  • Cardiac
  • Diabetic
  • Clear Liquids
  • Full liquids
  • Dysphasia Diet
  • TF
  • TPN
  • PPN

• Braden

• Pressure Sores?

  Select None (but at risk) Coccyx Boney Prominences Heals Stage 1 Stage 2 Stage 3

  • None (but at risk)
  • Coccyx
  • Boney Prominences
  • Heals
  • Stage 1
  • Stage 2
  • Stage 3

• Wounds

  Select R leg L leg R arm l arm Head Other

  • R leg
  • L leg
  • R arm
  • l arm
  • Head
  • Other

• Type of Venous Access?

  Central Line

  Mid Line

  PIV

• Type of Central Line

  Select IJ SC PICC Fem innominate Permacath medport

  • IJ
  • SC
  • PICC
  • Fem
  • innominate
  • Permacath
  • medport

• Action Needed?

  Nurse to ask Dr to change/dc

  No other access available

• Indication for Central Line?

  Select Medication CVP Monitoring TPN None (nurse to get Dced) Inappropriate but Dr wants to keep Blood draws Difficult Access

  • Medication
  • CVP Monitoring
  • TPN
  • None (nurse to get Dced)
  • Inappropriate but Dr wants to keep
  • Blood draws
  • Difficult Access

• Foley?

  Yes

  No

• Indication for Foley

  Select Accurate I/Os Retention Neurogenic Bladder Immobilized (vent fx hip/spine) End of life None (nurse to dc) Lasix

  • Accurate I/Os
  • Retention
  • Neurogenic Bladder
  • Immobilized (vent fx hip/spine)
  • End of life
  • None (nurse to dc)
  • Lasix

• Art Line

• Arterial Line

  Select Radial Brachial Femoral

  • Radial
  • Brachial
  • Femoral

• Arctic Sun

• Balloon Pump

• Sheath (heart Cath)

• NGT

• OGT

• Peg

• Chest Tube

• Number of CTs?

  1 CT

  2 CTs

  3 CTs

  4 CTs