This document is a brain sheet binder insert for a patient with the initials RM and age. It includes the patient's diagnosis, allergies, activity level, oxygen needs, IV access and fluids, pain medications, voiding information, fall and other precautions, fasting blood sugar monitoring schedule, requested labs and imaging, and morning and afternoon vital signs. Notes sections are left blank for the physician to document additional information.

1. BRAIN SHEET BINDER INSERT WITH MARS
RM# _______ PT: ____________________ age: ____ M / F Dr. __________________
DX: ________________________________________diet: ________________ d/weight
Allergies: ______________________________________________________________
O2 : _____ nebs activity: ↑ad lib / bed rest / ↑in chair / PT / walker / assist x
IV fluids: __________________________ access: ______________ PCA (dem / morph)
DNR pain meds (last dose?): _____________________________________________
voids: BRP / foley / BSC / urinal / diaper SNF / rehab consult (need / done)
UA / C&S (need / done) stool x ___ for guiac / c-diff / WBC
precautions: contact / fall / seizure / aspiration (HOB ↑ ___ °) / neuro√
FSBS: ac&hs / q ___ hrs / SS: regular insulin / Novolog
2100: ____________ 0730: ____________ 1130: ____________ 1630: _____________
labs: CBC / __MP / CE / BNP / Mag / Phos / K / Lytes / H&H / PT/INR / PTT / ________
CXR / EKG / Echo / MRI / US / CT _____________________ permit? Y / N √list? Y / N
VS 0600 T ______ P ______ R ______ BP ____________ O2 ______
_____ T ______ P ______ R ______ BP ____________ O2 ______
Notes:_________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Hx : __________________________________________________________________
Labs:
Na: _________
K: __________
BUN: ________
Creat: _______
WBC: _______
H/H: ________
Plat: ________