Cheat sheet - Plan of Care

1. Patient:
POD:
Diagnosis
A. Primary:
B. Secondary:
Allergies:
Code Status:
Anesthesia:
Mobility:
IVF:
Catheter:
DIET:
PAIN PCA:
Time:
BP
PR
RR
TEMP
O2 SAT
OTHER CONCERNS:
Medications:
Laboratory Results:
Focus:
Headto Toe assessment
Chestassessment
Abdominal Assessment
DVT
Peripheral VascularAssessment
NeuroVascularAssessment
GlasgowComaScale I&O
Thingsto do onfield:
1. Assessment
2. Basic care – dressing,charting,positioning,mouthcare
3. V/S
4. Glucometer
5. IN’sand OUT’s
Thingsto check:
Blue Book – Kardex,MAR(PCA,epidural,PRN meds),Nrsgflowsheet
RedBook – code sheet,signature sheet,admreportprimaryand
secondary,allergies,interdisciplinarynotes
Last Doctor’s Order: