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New Form 3
New Form 3
New Form 3
ascentiahealthcare
2022-10-07T20:35:54+00:00
Client Name
Date
Time
Hours
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00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Minutes
-
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
VENT TYPE
Mode
Set RR
Measured RR
Set VT
Measured VT
Total VE
Peak Airway Pr.
Pressure Support
FiO2
O2 Saturation
PEEP
Peak Flow
I : E Ratio
Sensitivity
High Pressure
Low Pressure
Low Exhaled Vol
Low Minute Vol.
Apne aSetting
Humidification
Vent Circuit
Nebulizer
HME
In-line Suction
OTHER
Cuff Pressure
Trach. Care
Trach. Size
ETT Size
Kind of TT
Level of ETT
VT
MV
RR
NIF
HHN / MDI
Time of Tx
HR: Pre
HR: Post
Duration Tx
Response to Tx
Breath Sounds
Respiration
Secretion:---Color
Amount
Consistency
Initial
Parameters
PH Time
Hours
Minutes
AM
PM
PH Time
PCO2 Time
Hours
-
12
01
02
03
04
05
06
07
08
09
10
11
Minutes
-
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
PCO2 Time
PO2 Time
Hours
-
12
01
02
03
04
05
06
07
08
09
10
11
Minutes
-
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
PO2 Time
HC03 Time
Hours
-
12
01
02
03
04
05
06
07
08
09
10
11
Minutes
-
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
HC03 Time
BE Time
Hours
-
12
01
02
03
04
05
06
07
08
09
10
11
Minutes
-
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
BE Time
SaO2 Time
Hours
-
12
01
02
03
04
05
06
07
08
09
10
11
Minutes
-
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
SaO2 Time
Response to Treatment
Well
Fair
Poor
Respirations
Shallow
Labored
Irregular
Distress
Sputum Color
Clear
Yellow
Gray
Green
Bloody
Brown
White
Sputum amount
Large
Moderate
Small
Non-Prod.
Breath Sounds
Clear
Rales
Wheeze
Diminished
Absent
Ronchi
Sp. Consistancy
Thick
Thin
Frothy
Name(s) of Nurse
Comments
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