PROVIDENCE HOSPITAL6801 Airport Boulevard, Mobile AL 36608,251/633−1000

nsg00195pg1Created: 05/2012 Date Printed:

Report Tool − NOT part of the Medical Record Level 12 Medical − Surgical Report Tool

RM: PATIENT: AGE: DOAdmit:

DX: CODE STATUS:ATTENDING MS: ISOLATION TYPE:CONSULTS:

ALLERGIES:

HISTORY:

SURGERY/PROCEDURES/AET/POD#:DRESSINGS: DRESSING CHANGE Q_______

NEURO/LOC:ACTIVITY: PT:FALL RISK SCORE: SAP: YES NOSEDATION/PAIN/SLEEP AID:BED ALARMS: ON OFFRESTRAINTS: YES NO RESTRAINT ORDER SIGNED & ON CHART: YES NO

ONCOLOGY:CHEMO: Yes No Type __________________________________Day#________________CBC: WBC_______Plt______Hgb_______Hct________BMP: Na______K______Mag______Bun______Cr____Narcotic Drip: ________________________________________________

CARDIAC: SAT. TELE: YES NO PULSES:COUMADIN: YES NO FLOWSHEET: YES NOSCD HOSE: YES NO TED HOSE: YES NO

PULMONARY: O2 @ TX: Q

GI: DIET: LAST BM:NGT: DRAINAGE & AMT:

BG: 0700____1100____1600____2100____0300____

GU: ❒ Foley ❒ I/O ❒ Voiding ❒ Dialysis/Date of Last Treatment________If Foley: Meet criteria to DC Foley? Yes No Was Foley removed at 4 AM? Yes No Time Foley DC’d: ____________Post DC Void? Yes No Amt: Freq:Is there an order for Foley to stay in? Yes No Date Foley to be removed: ____________

SKIN: POA?BRADEN SCORE: ET CONSULT: Yes NoSKIN CARE PROTOCOL: Prevention? or Treatment?

IV: DAY FLUIDS:Port: Yes No Picc: Yes No Location:ABX: DOSE #

POC: GOAL MET: YES NO

Did MD see pt. today? YES NO If NO, MD office notified? YES NOPhysician Orders reviewed: YES NOMD Progress Notes reviewed for Plan of Care: YES NOOrders need follow up? YES NOLab work/Procedures ordered for tomorrow:Database completed: YES NO Home Meds Confirmed: YES NOQuality Chart Check completed: YES NO

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SGY00017

PROVIDENCE HOSPITAL6801 Airport Boulevard, Mobile AL 36608,251/633−1000

Date Created 7/11 Date Printed:

Report Tool − NOT part of the Medical Record Surgical Report Tool

Surgery Report Tool

PRE−OP Nurse Giving Report: _________________________ Time Pre−Op Report Rec’d: ____________

Patient Name:Age: Code Status: HT________ WT________

Surgeon Name:Surgery Scheduled: NPO since:___________Allergies:Pertinent History:

PACU Nurse Giving Report: _________________________ Time PACU Report Rec’d: ____________Anesthesia End Time/PACU arrival: Type of Anesthesia: On Bed? YES NO

Procedure actually done:

EBL:Drain: Amt: Drain #2: Amt:Dressings:

Reinforced? YES NO Change: Q_________ by: Nurse MDFoley: YES NO Remove order: ___________ POA specimen sent? YES NOIV Access & therapy:

Time Patient Arrived From PACU to Nursing Unit: __________SCIP/Core Measures: For any of the following that will not meet criteria , the Physician, Physician’sAssistant, or Nurse Practitioner MUST document reason in Progress Notes within the same timeframegiven for each measure.

Preop Post−op

❒ ❒ CHF ❒ AMI

❒ ❒ Pneumonia Alert completed If Dx Pneumonia − ABX given within 4 hours ❒ Yes ❒ No

❒ ❒ Beta Blocker on Home Med List, dose given day of surgery BEFORE leaving PACU? Yes❍ If not, has reason been documented by physician? Yes No Reason doc’d

❒ ❒ VTE med ordered (Coumadin, Heparin, or Lovenox)? Yes No Reason doc’d❍ Given in Pre−op? Yes No PACU? Yes No INR Result:❍ First dose to be given when? (Must be within 24 hours of Surgery or

Reason doc’d)❒ ❒ SCD Sleeves on Pt Yes No❒ ❒ SCD Pump on Pt Yes No❒ ❒ TEDS on Pt Yes No

❒ ❒ Antibiotic ordered? Yes No Prophylactic Infection Being Treated:❍ Time most recent dose given? Next dose due:❍ Time last dose will be given: (Must be less than 24 hours after AET for

Prophylactic Antibiotics)❒ ❒ Order for when to remove Foley? POD#1 POD#2

❍ Reason for keeping Foley must be doc’d on POD#1 or POD#2

❒ ❒ SCIP Audit tool printed and completed