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GSS Scutsheet

This document contains a patient's hospital admission information including vital signs, intake and output, procedures, medications, past medical history, physical exam findings, and plan of care. Key details include the patient's room number, hospital day/post-op day, vital signs being monitored daily, intake and output, use of foley catheter and drains, administered medications and intravenous fluids, and planned imaging studies.

Uploaded by

Andy Fischer
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
1K views2 pages

GSS Scutsheet

This document contains a patient's hospital admission information including vital signs, intake and output, procedures, medications, past medical history, physical exam findings, and plan of care. Key details include the patient's room number, hospital day/post-op day, vital signs being monitored daily, intake and output, use of foley catheter and drains, administered medications and intravenous fluids, and planned imaging studies.

Uploaded by

Andy Fischer
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DOB:

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yo M/F

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Admit date:

Rm: / ! HD/POD#! Tm! Tc! P! BP! RR! O2 s m t w r f s! I/O: ! / yest! UOP:! yest foley/st cth/void npo/s&c/clr/soft/reg! ! / today! ! today foley/st cth/void ! ! Drains: ABX po/iv! ! PAIN MEDS po/iv! ! AC MEDS! ! ! ! ! ! ! IVF c/o! ! PAIN Y/N N / V / CP / SOB atus / BM / belch OOB ABD S / TTP / NT / ND / BS INC C / D / I erythema/hematoma/seroma ! ! ! ! ! ! ! Plan:

Procedure:

CC: HPI:

Imaging Y/N PMH:! ! ! ! ! PSH: / ! HD/POD#! Tm! Tc! P! BP! RR! O2 s m t w r f s! I/O: ! / yest! UOP:! yest foley/st cth/void npo/s&c/clr/soft/reg! ! / today! ! today foley/st cth/void ! ! Drains: ABX po/iv! ! PAIN MEDS po/iv! ! AC MEDS! ! ! ! ! ! ! IVF c/o! ! PAIN Y/N N / V / CP / SOB atus / BM / belch OOB ABD S / TTP / NT / ND / BS INC C / D / I erythema/hematoma/seroma ! ! ! ! ! ! ! Plan:

Meds:! !

All:

FH: Imaging Y/N

! ! ! ! ! !

! ! ! ! ! !

! ! ! ! ! !

! ! ! ! ! !

! ! ! ! ! !

SH: tobacco Y/N ___PPDx___yr ! quit: EtOH Y/N subs Y/N PysEx:

Studies:!

Consults:

/ ! HD/POD#! Tm! Tc! P! BP! RR! O2 s m t w r f s! I/O: ! / yest! UOP:! yest foley/st cth/void npo/s&c/clr/soft/reg! ! / today! ! today foley/st cth/void ! ! Drains: ABX po/iv! ! PAIN MEDS po/iv! ! AC MEDS! ! ! ! ! ! ! IVF c/o! ! PAIN Y/N N / V / CP / SOB atus / BM / belch OOB ABD S / TTP / NT / ND / BS INC C / D / I erythema/hematoma/seroma ! ! ! ! ! ! ! Plan:

Imaging Y/N

Gibbon Surgical Society / P.Bucciarelli

/ ! HD/POD#! Tm! Tc! P! BP! RR! O2 s m t w r f s! I/O: ! / yest! UOP:! yest foley/st cth/void npo/s&c/clr/soft/reg! ! / today! ! today foley/st cth/void ! ! Drains: ABX po/iv! ! PAIN MEDS po/iv! ! AC MEDS! ! ! ! ! ! ! IVF c/o! ! PAIN Y/N N / V / CP / SOB atus / BM / belch OOB ABD S / TTP / NT / ND / BS INC C / D / I erythema/hematoma/seroma ! ! ! ! ! ! ! Plan:

/ ! HD/POD#! Tm! Tc! P! BP! RR! O2 s m t w r f s! I/O: ! / yest! UOP:! yest foley/st cth/void npo/s&c/clr/soft/reg! ! / today! ! today foley/st cth/void ! ! Drains: ABX po/iv! ! PAIN MEDS po/iv! ! AC MEDS! ! ! ! ! ! ! IVF c/o! ! PAIN Y/N N / V / CP / SOB atus / BM / belch OOB ABD S / TTP / NT / ND / BS INC C / D / I erythema/hematoma/seroma ! ! ! ! ! ! ! Plan:

Imaging Y/N / ! HD/POD#! Tm! Tc! P! BP! RR! O2 s m t w r f s! I/O: ! / yest! UOP:! yest foley/st cth/void npo/s&c/clr/soft/reg! ! / today! ! today foley/st cth/void ! ! Drains: ABX po/iv! ! PAIN MEDS po/iv! ! AC MEDS! ! ! ! ! ! ! IVF c/o! ! PAIN Y/N N / V / CP / SOB atus / BM / belch OOB ABD S / TTP / NT / ND / BS INC C / D / I erythema/hematoma/seroma ! ! ! ! ! ! ! Plan:

Imaging Y/N / ! HD/POD#! Tm! Tc! P! BP! RR! O2 s m t w r f s! I/O: ! / yest! UOP:! yest foley/st cth/void npo/s&c/clr/soft/reg! ! / today! ! today foley/st cth/void ! ! Drains: ABX po/iv! ! PAIN MEDS po/iv! ! AC MEDS! ! ! ! ! ! ! IVF c/o! ! PAIN Y/N N / V / CP / SOB atus / BM / belch OOB ABD S / TTP / NT / ND / BS INC C / D / I erythema/hematoma/seroma ! ! ! ! ! ! ! Plan:

Imaging Y/N / ! HD/POD#! Tm! Tc! P! BP! RR! O2 s m t w r f s! I/O: ! / yest! UOP:! yest foley/st cth/void npo/s&c/clr/soft/reg! ! / today! ! today foley/st cth/void ! ! Drains: ABX po/iv! ! PAIN MEDS po/iv! ! AC MEDS! ! ! ! ! ! ! IVF c/o! ! PAIN Y/N N / V / CP / SOB atus / BM / belch OOB ABD S / TTP / NT / ND / BS INC C / D / I erythema/hematoma/seroma ! ! ! ! ! ! ! Plan:

Imaging Y/N / ! HD/POD#! Tm! Tc! P! BP! RR! O2 s m t w r f s! I/O: ! / yest! UOP:! yest foley/st cth/void npo/s&c/clr/soft/reg! ! / today! ! today foley/st cth/void ! ! Drains: ABX po/iv! ! PAIN MEDS po/iv! ! AC MEDS! ! ! ! ! ! ! IVF c/o! ! PAIN Y/N N / V / CP / SOB atus / BM / belch OOB ABD S / TTP / NT / ND / BS INC C / D / I erythema/hematoma/seroma ! ! ! ! ! ! ! Plan:

Imaging Y/N

Imaging Y/N

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