Please be thorough with your supportive care.
In doing so, you will not forget to place or discontinue orders (e.g. if you write an assessment on fluids daily, you will remember to d/c when appropriate and not iatrogenically cause pulmonary edema or electrolyte derangements). It also reminds you of ancillary care you may need, and allows you to assess lines/Foleys/etc daily. This is the format I have created and use with my interns/students, and I encourage you to use this or something similar and save it as a macro.
– Code: Full
– DVT PPx: Heparin 5000 U subQ
– GI PPx: None indicated at this time
– Diet: Regular
– Bowel Reg: Senna/Colace
– Sedation/Pain meds: (what and why)
– Fluids: None indicated at this time
– Lines: (type, placement, date, and why if it’s a central)
– Vaccination status: (influenza/pneumococcal/zoster/tetanus). ask if they want their influenza prior to d/c.
– HIV status: (if neg, please type last neg date. If pos, please put last CD4 count and date).
– Dispo: Home in 1-2 days pending resolution of **