Patient screening and exclusion record

Medical IV Hydration Business | PublicProof Academy working document

Non-editable educational sample of record categories. Not an approved clinical form or treatment protocol. A qualified professional must review suitability before use in their own secure system.

Business

State or jurisdiction

Prepared on

Owner

Official source saved

Next review

Before any line is started

Photo ID checked and age confirmed
Health history completed and signed by the patient
Current medications and supplements recorded
Known allergies recorded, including to additives on the menu
Vitals taken and recorded (BP, pulse, SpO2, temperature)
Pregnancy status asked where relevant
Prescriber evaluation completed and order received for THIS patient today
Informed consent signed, including risks of infiltration, infection and allergic reaction

Automatic stop - escalate to the prescriber

Known cardiac, renal or liver disease
Uncontrolled hypertension or abnormal vitals
Pregnancy
Signs of acute illness that belong in an emergency department
Prior reaction to any additive on the menu
Intoxication or inability to give informed consent
Patient requesting an additive the prescriber has not approved

Decline log

Date and time of decline
Reason for decline in clinical terms
Who made the decision (nurse or prescriber)
What the patient was advised to do instead
Refund or no charge confirmed

Use rule: Education and organization only. Record the agency, official source, checked date, cost, proof saved and responsible person for every consequential requirement. Unknown means stop and confirm. Example rows are labeled EXAMPLE and are not your data.