Patient Name: Age: Room #: Allergies: Code Status: Full/DNR/Modified

Handoff Report

Patient name: Age: Room #: Allergies: Code status: Full/DNR/modified

Admitting dx: PMH:

Family password:

Mental Health findings/Orientation:

Orders: Activity level: Up ad lib/BR/ BRBP Diet: Regular/diabetic/NPO/other_____

Last VS & pulse ox: Oxygen order:

Ordered FSBS: Last result: Insulin/SS:

Precautions: Fall/Seizure/Skin/Aspiration Fall risk score: Braden Scale Score:

Significant wounds present:

Interventions for prevention:

Last bath and oral care:

IV access (location, gauge)______IV Fluids and rate______

PCA orders (med/basal/pca dose)______

Significant medications:

Therapy: PT/OT/Speech

Significant other assessments:

Voids (urine/stool): Continent/Incontinent Foley: Yes/No If yes, diagnosis for having one:

Last BM:

Shift total intake/output______/______Today’s weight (kg)______Admitting wt______

Difference of______kgs

Normal or abnormal significant labs (trend):

Significant diagnostic exams:

Pending labs or other tests:

Other MD orders:

Patient education needs: