Heading
Name
First Name
Last Name
Age
Room
From Hospital
Adm to WH
-
Month
-
Day
Year
Date
Reason for Hospitalization
Height
Weight
LOC x
H/O Falls
Bariatric Equipment
Bed
Chair
Commode
Shower Chair
Wheelchair
Oxygen @
LPM via
Select all that apply
Ostomy
Catheter
IV/PICC
Wound Vac
BIPAP with Settings
CPAP with Settings
Dialysis with Days/Chair Time/Location
Additional Information
PRISM LEVEL
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