Summary – Rubin Billie Client Charts
Patient Summary
| MRP | ||||||
| Admit Date | ||||||
| Primary Diagnosis | ||||||
| SECONDARY DIAGNOSES | ||||||
| Implanted Device | ||||||
| Blood Consent | Blood Type: | |||||
| Aggression | History of Violence: | Physically Aggresive: | ||||
| Behaviour | Verbally Aggresive: | Violence Prevention Toolkit: | ||||
| Religion | ||||||
| OXYGEN | SUCTION | |||||
| SURGERY | ||||||
| DRAIN | ||||||
| WOUND | ||||||
| Isolation | Code Status: | Link to MOST | ||||
| Substance Use | Last Use: | |||||
| Alcohol Use | Last Use: | |||||
| Tabacco Dependence: | Last Use: | |||||
| ALLERGIES | Reaction type: | Severity: | ||||
| Reaction type: | Severity: | |||||
| Reaction type: | Severity: | |||||
| DIET | ||||||
Patient Monitoring
| DIET | ||||||
| V S | DAY | Temp (F) | Pulse | Resp Rate | BP | O2 |
| I & O | ||||||
| FOLEY | Day | Night | DC date: | |||
| TUBES | Type: | Type: | ||||
| IV Lines: | Pain: | Pain Level: | ||||
| Collection: | Intake: | Output: | ||||
| Pending Tests & Diagnostics: | ||||||
| Appointments: | ||||||
| Blood Glucose (Time/ Reading) | ||||||
Vital Signs
| DAY | ||||||||
| TIME | ||||||||
| TEMPERATURE | ||||||||
| PULSE | ||||||||
| RESPIRATION | ||||||||
| BLOOD PRESSURE | ||||||||
| O2 SAT | ||||||||
| WEIGHT | ||||||||
| Initials | ||||||||
| DAY | ||||||||
| TIME | ||||||||
| TEMPERATURE | ||||||||
| PULSE | ||||||||
| RESPIRATION | ||||||||
| BLOOD PRESSURE | ||||||||
| O2 SAT | ||||||||
| Weight | ||||||||
| Initials | ||||||||
| DAY | ||||||||
| TIME | ||||||||
| TEMPERATURE | ||||||||
| PULSE | ||||||||
| RESPIRATION | ||||||||
| BLOOD PRESSURE | ||||||||
| O2 SAT | ||||||||
| Weight | ||||||||
| Initials | ||||||||
