paper chart outline

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FOR FURTHER QUESTIONS ASK YOUR MANAGER OR CPM
Goals of Care
Allergy Sheet

Flow Sheets
  • Oldest to newest
  • 24 hour patient care
  • Vitals
MAR


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Orders

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Interdisciplinary Patient Progress 
  • All interdisciplinary notes are filed here (MRP/PT/OT/SLP/Nursing/RT)
  • Chronological Order (OLDEST TO NEWEST)
  • Each discipline to identify designation on column prior to starting notes including date and time
  • Final signature includes designation
  • Practitioner notes located back of progress notes

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Tests/Lab
  • Lab Value Tracker
  • Lab Values
  • DI Results (XR/CT/US)
  • ECG/Tele Strips
  • Chronological Order (Oldest to Newest)
  • Other