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RN__________________ Volunteer_________________ Date__________ Time__________ Patients Name __________________ Last 4 SS# __________ DOB _________ Room # ___________ Weight ___________ Temperature ____________ Contact Precautions Yes / No __________________________________ PATIENT GENERAL CONDITIONAwake / Able to communicate / Confused (Circle all that apply)In Bed / In Chair / Standing / In Bathroom (Circle one)Bath Bathed themselves Yes / NoBath Bed bath given Yes / NoMouth Care given Yes / NoWalking can walk without help for _______ minutesWalk with help for _______ minutesASSISTANCE GIVEN TO PATIENTBed to bathroom / commode Yes / NoOut of bed to chair / wheelchair Yes / NoOut of bed walking Yes / NoBedding Changed Yes / NoFEEDINGIce Chips given (I&O recorded) Yes / NoMeal Provided (I&O recorded) Yes / No Breakfast / Lunch / DinnerHelp needed (I&O recorded) Yes / NoPatient ate 25%, 50% 75% or 100% of food on plate (Circle one)ELIMINATIONBowel movement Yes / NoSpecimens taken to the Lab Yes / NoTo Where?Patient transport Yes / NoTo Where?INTAKE/OUTPUTTIMELIQUID INTAKEURINE OUTPUTTOTAL  m {  0 < > ? @     8 > G I J K m o p     Z [ \ ] ѿh}h}>*CJh}h}6CJh} hh}h}h}CJhh}CJhYNh}CJaJhYNh}56CJhYNh}B*CJphhYNh}6CJ? 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When you complete the task check the box on the right.<.G.../..*+*..//<<..**/.*+...../.S...(..*.G......*+*..)+....*......TTBz/@@iLP - Rp@"Arial`" %D#RO`2%" ,$%$O`2%" o.1"% 2o.1X3. * Arial`2x`2X2D"9'1,#,#z%1T#2dv% % %  TQ/@@<MLRN__________________ Volunteer_________________ Date__________ Time__________HH888878788787887888C87878!88787878878878878H887887887888>T78878787887TTQ/@@<LP 6Rp @"Arial%D#RO`2%" ,$%$O`2%" o.1"% 2o.1X3. * Arial`2x`2X2D"9'1,#,#z%1T#2dvdv% Rp@"Arial2o.1 Ct| <$$ E* E!]||! @w!wJ Z , XX  / !.<"!|<<""wYwdv% ( Rp @"Arial E* E! 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P 3" ! !  % % %  T@ o  /@@@ "L ! Walk with help for _______ minutesa72G88888!7878878T8881% % % TTp  /@@p L ! P 3" ! s!  % % %  TT  /@@ L s! P 3" % Ldu x u !??%  % Ldy  y !??%  % Ld   !??%  % Ld   !??%  % Ld   !??%  % Ld r  !??%  % Lds v s !??%  % Ldu x u s!??%  % Ld   s!??%  % Ld   s!??%  % Lds v s s!??%    '% Ldy%  y% +s!??% (      '% LdH% r H% +s!??% (   !y% s    '% Ld% G &" WMFC ll% s!??% (    % % %  T'  /@@ Ly% s ASSISTANCE GIVEN TO PATIENTCCCB=CHHCNBCH>NCB>CG=% % % TT . B /@@ Ly% s P 3" % Ldu! x$ u! !??%  % Ldy! $ y! !??%    % Ld! $ ! !??%  % Ld! $ ! !??%    % Ld! $ ! !??%  % Ld! r$ ! !??%  % Lds! v$ s! !??%  % Ldu% x u% s!??%  % Lds% v s% s!??% !y   % % %  TT  /@@ Ly  P 3" !   % % %  T@ /@@@ =L  Bed to bathroom / commode Yes / NoC888788 87T18ST878B82H7% % % TT /@@ L  P 3" ! s  % % %  TT  /@@ L s P 3" % Ldu x u !??%  % Ldy  y !??%  % Ld   !??%  % Ld   !??%  % Ld   !??%  % Ld r  !??%  % Lds v s !??%  % Ldu x u s!??%  % Ld   s!??%  % Ld   s!??%  % Lds v s s!??% !y   % % %  TT { /@@h Ly  P 3" !   % % %  Tt@ /@@@o 1L  Out of bed to chair / wheelchair YesN877888278!G888278!B82Tp  /@@ o L  X T  /@@ o L  `/ NoG7% % % TT  /@@ o L  P 3" ! s  % % %  TT { /@@h L s P 3" % Ldu x u !??%  % Ldy  y !??%  % Ld   !??%  % Ld   !??%  % Ld   !??%  % Ld r  !??%  % Lds v s !??%  % Ldu x u s!??%  % Ld   s!??%  % Ld   s!??%  % Lds v s s!??% !y   % % %  TT  /@@ Ly  P 3" !   % % %  T@ /@@@ FL  Out of bed walking Yes &" WMFC ll / NoN87788G8287B82H7TT /@@ L  P 8" ! s  % % %  TT  /@@ L s P 3" % Ldu x u !??%  % Ldy  y !??%  % Ld   !??%  % Ld   !??%  % Ld   !??%  % Ld r  !??%  % Lds v s !??%  % Ldu x u t!??%  % Ld   t!??%  % Ld   t!??%  % Lds v s t!??% !y u  % % %  TT j /@@W Ly u P 3" ! u  % % %  T@ s /@@@^ DL u Bedding Changed Yes / NoC88887H888788B82H7% % % TT q /@@ ^ L u P 3" ! su  % % %  TT j /@@W L su P 3" % Ldu x u !??%  % Ldy  y !??%  % Ld   !??%  % Ld   !??%  % Ld   !??%  % Ld r  !??%  % Lds v s !??%  % Ldu xt u s!??%  % Ld t  s!??%  % Ld t  s!??%  % Lds vt s s!??%    '% Ldyy  yy +s!??% (      '% LdHy r Hy +s!??% (   !yy s    '% Ldy G y s!??% (    % % %  Tx { /@@ Lyy s \FEEDING=CCHHN% % % TT  /@@ Lyy s P 3" % Lduu xx uu !??%  % Ldyu x yu !??%    % Ldu x u !??%  % Ldu x u !??%    % Ldu x u !??%  % Ldu rx u !??%  % Ldsu vx su !??%  % Lduy x uy s!??%  % Ldsy v sy s!??% !y c % % %  TT X/@@ELy cP 3" ! c % % %  T@ a/@@@L>L cIce Chips given (I&O recorded) Yes / No28H8827188!CN 828!878!&" WMFC llB82G7TT a/@@ LL cP 8" ! sc % % %  TT X/@@EL scP 3" % Ldu x u !??%  % Ldy  y !??%  % Ld   !??%  % Ld   !??%  % Ld   !??%  % Ld r  !??%  % Lds v s !??%  % Ldu xbu s!??%  % Ld b s!??%  % Ld b s!??%  % Lds vbs s!??% !yg % % %  TTi/@@LygP 3" !g % % %  T@i/@@@LglMeal Provided (IS88C!81888!Ti/@@ALg&O recorded) Yes / No Breakfast / Lunch / DinnerCM!728!888!B82G7C!7818187828H878!% % % TTp/@@LgP 3" !gs % % %  TTi/@@LgsP 3" % Lducxfuc!??%  % Ldycfyc!??%  % Ldcfc!??%  % Ldcfc !??%  % Ldcfc!??%  % Ldcrfc!??%  % Ldscvfsc!??%  % Ldugxugs!??%  % Ldggs!??%  % Ldggs!??%  % Ldsgvsgs!??% !yQ % % %  TTF/@@3LyQP 3" !Q % % %  Th@ O/@@@:/LQHelp needed (I&O recorded) Yes / NoH88878878!CM!827!888!B82H7% % % TT C M/@@ :LQP 3" !sQ % % %  TTF/@@3LsQP 3" % Lduxu!??%  % Ldyy!??%  % Ld!??%  % Ld !??%  % Ld!??%  % Ldr!??%  % Ldsvs!??%  % LduxPus!??%  % LdPs!??%  % LdPs!??%  % LdsvPss!??% !yV % % %  TTX/@@LyVP 3" !V % % %  Tx@W_ /@@@2LVPatient ate 25%, 50% 75% or 100% of food o&" WMFC lln plate C8878878Y88Y88Y8!887Y778878888% % % T` Wc/@@`  LVd(Circle one)!H!28888 % % % TTd^/@@dLVP 3" !Vs % % %  TTX/@@LVsP 3" % LduQxTuQ!??%  % LdyQTyQ!??%  % LdQTQ!??%  % LdQTQ !??%  % LdQTQ!??%  % LdQrTQ!??%  % LdsQvTsQ!??%  % LduUxuUt!??%  % LdUUt!??%  % LdUUt!??%  % LdsUvsUt!??%    '% Ldy?y+s!??% (      '% LdHr?H+s!??% (   !ys@   '% LdG?s!??% (    % % %  T4 >/@@) Lys@dELIMINATIONC8SHB>NG% % % TT5 g </@@5 )Lys@P 3" % Lduxu!??%  % Ldyy!??%    % Ld!??%  % Ld !??%    % Ld!??%  % Ldr!??%  % Ldsvs!??%  % Ldux?us!??%  % Ldsv?ss!??% !yD % % %  TTF/@@LyDP 3" !D % % %  T@FB /@@@9LDBowel movement Yes C8G8T818T78B82TTC F^ /@@C LDP T_ F /@@_  LD`/ NoH7% % % TT M /@@ LDP 3" !Ds % % %  TTF/@@LDsP 3" % Ldu@xCu@!??%  % Ldy@Cy@!??%  % Ld@C@!??%  % Ld@C@ !??%  % Ld@C@!??%  % Ld@rC@!??%  % Lds@vCs@!??%  % LduDxuDs!??%  % LdDDs!??%  % LdDDs!??%  % LdsDvsDs!??% !y. % % %  TT#/@@Ly.P 3" !. % % %  T@&" WMFC lyl ,/@@@>L.Specimens taken to the Lab Yes / NoC882T8828278878878B82H7% % % TT  */@@ L.P 3" !s. % % %  TT#/@@Ls.P 3" % Lduxu!??%  % Ldyy!??%  % Ld!??%  % Ld !??%  % Ld!??%  % Ldr!??%  % Ldsvs!??%  % Ldux-us!??%  % Ld-s!??%  % Ld-s!??%  % Ldsv-ss!??% !y2 % % %  TT4/@@Ly2P 3" !2 % % %  T@4./@@@ L2`To Where?>7b77!87% % % TT/;a/@@/L2P 3" !2s % % %  TT4/@@L2sP 3" % Ldu.x1u.!??%  % Ldy.1y.!??%  % Ld.1.!??%  % Ld.1. !??%  % Ld.1.!??%  % Ld.r1.!??%  % Lds.v1s.!??%  % Ldu2xu2s!??%  % Ld22s!??%  % Ld22s!??%  % Lds2vs2s!??% !y % % %  TT/@@LyP 3" ! % % %  T@ /@@@FLPatient transport Yes / NoC887!78288!B82H7% % % TT  /@@ LP 3" !s % % %  TT/@@LsP 3" % Lduxu!??%  % Ldyy!??%  % Ld!??%  % Ld !??%  % Ld!??%  % Ldr!??%  % Ldsvs!??%  % Lduxus!??%  % Lds!??%  % Lds!??%  % Ldsvss!??% !y! % % %  TT#/@@vLy!P 3" !! % % %  T@#./@@@} L!`To Where?>7b77!87% % % TT/*&" WMFC lYla/@@/}L!P 3" !!s % % %  TT#/@@vL!sP 3" % Lduxu!??%  % Ldyy!??%  % Ld!??%  % Ld !??%  % Ld!??%  % Ldr!??%  % Ldsvs!??%  % Ldu xu s!??%  % Ld  s!??%  % Ld  s!??%  % Lds vs s!??%    '% Ldy y+s!??% (      '% LdHr H+s!??% (   !ys    '% LdG s!??% (    % % %  Tf /@@f Lys hINTAKE/OUTPUTH>CBCNG>CG=% % % TT  /@@ Lys P 3" % Lduxu!??%  % Ldyy!??%    % Ld!??%  % Ld !??%    % Ld!??%  % Ldr!??%  % Ldsvs!??%  % Ldux ut!??%  % Ldsv st!??% !y % % %  Td/@@kLyTTIME>SB% % % TT~/@@kLyP 3" !#  % % %  T^ /@@k L# hLIQUID INTAKE8NHHG>CBB% % % TT_  ~/@@_ kL# P 3" ! s % % %  T)/@@)k L sdURINE OUTPUTHHHCNH>CG=% % % TTI~/@@kL sP 3" % Ldu xu !??%  % Ldy y !??%  % Ld " !??%  % Ld#  # !??%  % Ld   !??%  % Ld r !??%  % Lds vs !??%  % Lduxu!??%  % Ld"!??%  % Ld   !??%  % Ldsvs!??% !y % % %  TT/@@LyP 3" !#  % % %  TTN/@@NL# P 3" ! s % % %  TT * /@@ L sP 3" % Lduxu!??%  % Ldyy!??%  %&" WMFC l9l Ld"!??%  % Ld# #!??%  % Ld   !??%  % Ld r !??%  % Ldsvs!??%  % Lduxuj!??%  % Ld"j!??%  % Ld   j!??%  % Ldsvsj!??% !y t % % %  TT s/@@`Ly tP 3" !#  t % % %  TTN s/@@N`L#  tP 3" ! st % % %  TT * s/@@ `L stP 3" % Ldux u!??%  % Ldy y!??%  % Ld" !??%  % Ld# #!??%  % Ld   !??%  % Ld r  !??%  % Ldsv s!??%  % Ldu xsu i!??%  % Ld "s i!??%  % Ld  s i!??%  % Lds vss i!??% !yx % % %  TTz/@@LyxP 3" !#x  % % %  TTNz/@@NL#x P 3" ! xs % % %  TT z* /@@ L xsP 3" % Ldutxwut!??%  % Ldytwyt!??%  % Ldt"wt!??%  % Ld#t w#t!??%  % Ld t w t!??%  % Ld trw t!??%  % Ldstvwst!??%  % Lduxxuxj!??%  % Ldx"xj!??%  % Ld x  xj!??%  % Ldsxvsxj!??% !yO % % %  TTN/@@;LyOP 3" !# O % % %  TTNN/@@N;L# OP 3" ! sO % % %  TT * N/@@ ;L sOP 3" % Lduxu!??%  % Ldyy!??%  % Ld"!??%  % Ld# #!??%  % Ld   !??%  % Ld r !??%  % Ldsvs!??%  % LduxNui!??%  % Ld"Ni!??%  % Ld  N i!??%  % LdsvNsi!??&" WMFC ll% !yT % % %  TTV/@@LyTP 3" !#T  % % %  TTNV/@@NL#T P 3" ! Ts % % %  TT V* /@@ L TsP 3" % LduOxRuO!??%  % LdyORyO!??%  % LdO"RO!??%  % Ld#O R#O!??%  % Ld O R O!??%  % Ld OrR O!??%  % LdsOvRsO!??%  % LduSxuSj!??%  % LdS"Sj!??%  % Ld S  Sj!??%  % LdsSvsSj!??% !y+ % % %  TT)/@@Ly+P 3" !# + % % %  TTN)/@@NL# +P 3" ! s+ % % %  TT * )/@@ L s+P 3" % Lduxu!??%  % Ldyy!??%  % Ld"!??%  % Ld# #!??%  % Ld   !??%  % Ld r !??%  % Ldsvs!??%  % Ldux*uj!??%  % Ld"*j!??%  % Ld  * j!??%  % Ldsv*sj!??% !y/ % % %  TT1/@@Ly/P 3" !#/  % % %  TTN1/@@NL#/ P 3" ! /s % % %  TT 1* /@@ L /sP 3" % Ldu+x.u+!??%  % Ldy+.y+!??%  % Ld+".+!??%  % Ld#+ .#+!??%  % Ld + . +!??%  % Ld +r. +!??%  % Lds+v.s+!??%  % Ldu/xu/i!??%  % Ld/"/i!??%  % Ld /  /i!??%  % Lds/vs/i!??% !y % % %  TT/@@LyP 3" !#  % % %  TTN/@@NL# P 3" ! s % % %  TT * /@@ L sP 3" % Lduxu!??%  % Ldyy!??%  % Ld"!??%  % Ld# #!??%  % Ld   !??% &WMFC ll  % Ld r !??%  % Ldsvs!??%  % Lduxuj!??%  % Ld"j!??%  % Ld   j!??%  % Ldsvsj!??% !y } % % %  Tl {/@@fLy }XTOTAL>M>B7% % % TTy/@@fLy }P 3" !#  } % % %  TTN r/@@N_L#  }P 3" ! s} % % %  TT * r/@@ _L s}P 3" % Ldux u!??%  % Ldy y!??%  % Ld" !??%  % Ld# #!??%  % Ld   !??%  % Ld r  !??%  % Ldsv s!??%  % Ldu x|u s!??%  % Ldu}xu}!??%  % Ldu}xu}!??%  % Ldy}y}!??%  % Ld "| s!??%  % Ld}"}!??%  % Ld#} #}!??%  % Ld  | s!??%  % Ld }  }!??%  % Ld }r }!??%  % Lds v|s s!??%  % Lds}vs}!??%  % Lds}vs}!??% % % %   TT/@@LP 1% % ( 666666666666666666666666666666666666 6 66 6  6 66 6  6 66 6  6 66 6  6 66 6 66666666666666666666  ."System--@"Arial--- (2 E#Volunteer Checklistp    2 E @"Arial--- 2 VBoComplete the tasks that the RN has checked on the left. When you complete the task check the box on the right.    2 V  @"Arial---2 t;MRN__________________ Volunteer_________________ Date__________ Time__________     2 t~  @"Arial-@"Arial- @"Arial-@"Arial- @"Arial--=2 ;!Patients Name __________________    2 ) 2 6 Last 4 SS# _ 2  _________# 2  2  DOB _________  2 F &2 ;Room # ___________   2   2  *(2 Weight ___________ p 2  /2 Temperature ____________   2 e (2 ;Contact Precautions_   2  )2 Yes /  2  2 6No  2 H >2 `"__________________________________ 2 h  2 ;  - @ ! 5-  - @ ! - , 5@"Arial--- - @ !S ;- ---12 5 PATIENT GENERAL CONDITION     --- 2 5  '- @ ! 4-- @ ! 4-- @ !_ 5-- @ ! -- @ ! -- @ ! 4-- @ ! -,+n5---  2 &;5n* ',+Vn@"Arial------ L2 't+nV*Awake / Able to communicate / Confused    ---.2 'nV*(Circle all that apply) --- 2 'nV* ',+W---  2 &]W* '- @ !4-- @ !95-- @ !n-- @ !n-- @ !V-- @ !=W-- @ !-- @ !4-- @ !n-- @ !V-- @ !-,;n+5---  2 7;5+n; ',;V+n--- R2 8t/n+V;In Bed / In Chair / Standing / In Bathroom      ---2 8 n+V;(Circle one) --- 2 8n+V; ',;+W---  2 7]W+; '- @ !*4-- @ !9*5-- @ !*n-- @ !*n-- @ !*V-- @ !=*W-- @ !*-- @ !+4-- @ !+n-- @ !+V-- @ !+-,Ln<5---  2 H;5<nL ',LV<n--- 2 Itn<VLBath N  2 In<VL 2 In<VL a2 I9n<VLBathed themselves Yes / No    --- 2 In<VL ',L<W---  2 H]W<L '- @ !;4-- @ !9;5-- @ !;n-- @ !;n-- @ !;V-- @ !=;W-- @ !;-- @ !<4-- @ !<n-- @ !<V-- @ !<-,]nM5---  2 X;5Ln] ',]VMn--- 2 YtnLV]Bath N  2 YnLV] 2 YnLV] e2 Y<nLV]Bed bath given Yes / No   --- 2 YnLV] ',]MW---  2 X]WL] '- @ !L4-- @ !9L5-- @ !Ln-- @ !Ln-- @ !LV-- @ !=LW-- @ !L-- @ !L4-- @ !Ln-- @ !LV-- @ !L-,mn]5---  2 i;5]nm ',mV]n--- [2 jt5n]VmMouth Care given Ye   #2 j|n]Vms / No  2 jn]Vm ',m]W---  2 i]W]m '- @ !]4-- @ !9]5-- @ !]n-- @ !]n-- @ !]V-- @ !=]W-- @ !]-- @ !]4-- @ !]n-- @ !]V-- @ !]-,~nn5---  2 z;5nn~ ',~Vnn--- 2 {tnnV~Walking  2 {nnV~ 2 {nnV~ 22 {nnV~can walk without help for   @ Arial------2 {RnnV~______- @ !/|R- 2 { nnV~_ minutes --- 2 {nnV~ ',~nW---  2 z]Wn~ '- @ !m4-- @ !9m5-- @ !mn-- @ !mn-- @ !mV-- @ !=mW-- @ !m-- @ !n4-- @ !nn-- @ !nV-- @ !n-,n~5---  2 ;5~n ',V~n--- >2 t"n~VWalk with help for _______ minutes  --- 2 Rn~V ',~W---  2 ]W~ '- @ !~4-- @ !9~5-- @ !~n-- @ !~n-- @ !~V-- @ !=~W-- @ !~-- @ !~4-- @ !~n-- @ !~V-- @ !~- - @ !5-   - @ !-  ,5 - @ !S;-  --- 42 5ASSISTANCE GIVEN TO PATIENT       --- 2 5 '- @ !4-- @ !95-- @ !n-- @ !n-- @ !V-- @ !=W-- @ !-- @ !4-- @ !-,n5---  2 ;5n ',Vn--- g2 t=nVBed to bathroom / commode Yes / Noo     --- 2 nV ',W---  2 ]W '- @ !4-- @ !95-- @ !n-- @ !n-- @ !V-- @ !=W-- @ !-- @ !4-- @ !n-- @ !V-- @ !-,n5---  2 ;5n ',Vn--- U2 t1nVOut of bed to chair / wheelchair Yes   2 nV 2  nV/ No --- 2 nV ',W---  2 ]W '- @ !4-- @ !95-- @ !n-- @ !n-- @ !V-- @ !=W-- @ !-- @ !4-- @ !n-- @ !V-- @ !-,n5---  2 ;5n ',Vn--- t2 tFnVOut of bed walking Yes / No     2 nV ',W---  2 ]W '- @ !4-- @ !95-- @ !n-- @ !n-- @ !V-- @ !=W-- @ !-- @ !4-- @ !n-- @ !V-- @ !-,n5---  2 ;5n ',Vn--- q2 tDnVBedding Changed Yes / No    --- 2 nV ',W---  2 ]W '- @ !4-- @ !95-- @ !n-- @ !n-- @ !V-- @ !=W-- @ !-- @ !4-- @ !n-- @ !V-- @ !- - @ !5-   - @ !-  ,5 - @ !S;-  --- 2 E5FEEDING  --- 2 5 '- @ !4-- @ !95-- @ !n-- @ !n-- @ !V-- @ !=W-- @ !-- @ !4-- @ !-,n5---  2 ;5n ',Vn--- h2 t>nVIce Chips given (I&O recorded) Yes / No     2 nV ',W---  2 ]W '- @ !4-- @ !95-- @ !n-- @ !n-- @ !V-- @ !=W-- @ !-- @ !4-- @ !n-- @ !V-- @ !-,n5---  2 ;5n ',Vn--- #2 tnVMeal Provided (I  m2 AnV&O recorded) Yes / No Breakfast / Lunch / Dinner     --- 2 OnV ',W---  2 ]W '- @ !4-- @ !95-- @ !n-- @ !n-- @ !V-- @ !=W-- @ !-- @ !4-- @ !n-- @ !V-- @ !-,$n5---  2 ;5n$ ',$Vn--- R2 !t/nV$Help needed (I&O recorded) Yes / No    --- 2 !nV$ ',$W---  2 ]W$ '- @ !4-- @ !95-- @ !n-- @ !n-- @ !V-- @ !=W-- @ !-- @ !4-- @ !n-- @ !V-- @ !-,5n%5---  2 1;5%n5 ',5V%n--- V2 2t2n%V5Patient ate 25%, 50% 75% or 100% of food on plate     ---2 2 n%V5(Circle one) --- 2 2n%V5 ',5%W---  2 1]W%5 '- @ !$4-- @ !9$5-- @ !$n-- @ !$n-- @ !$V-- @ !=$W-- @ !$-- @ !%4-- @ !%n-- @ !%V-- @ !%- - @ !65-   - @ !6-  ,F65 - @ !S6;-  --- 2 C8 56FELIMINATION    --- 2 C56F '- @ !54-- @ !955-- @ !5n-- @ !5n-- @ !5V-- @ !=5W-- @ !5-- @ !64-- @ !6-,WnF5---  2 R;5FnW ',WVFn--- a2 St9nFVWBowel movement Yes      2 SnFVW 2 S nFVW/ No --- 2 SnFVW ',WFW---  2 R]WFW '- @ !F4-- @ !9F5-- @ !Fn-- @ !Fn-- @ !FV-- @ !=FW-- @ !F-- @ !F4-- @ !Fn-- @ !FV-- @ !F-,gnW5---  2 c;5Wng ',gVWn--- h2 dt>nWVgSpecimens taken to the Lab Yes / No    --- 2 dnWVg ',gWW---  2 c]WWg '- @ !W4-- @ !9W5-- @ !Wn-- @ !Wn-- @ !WV-- @ !=WW-- @ !W-- @ !W4-- @ !Wn-- @ !WV-- @ !W-,xnh5---  2 t;5hnx ',xVhn--- 2 ut nhVxTo Where? --- 2 unhVx ',xhW---  2 t]Whx '- @ !g4-- @ !9g5-- @ !gn-- @ !gn-- @ !gV-- @ !=gW-- @ !g-- @ !h4-- @ !hn-- @ !hV-- @ !h-,nx5---  2 ;5xn ',Vxn--- t2 tFnxVPatient transport Yes / No   --- 2 nxV ',xW---  2 ]Wx '- @ !x4-- @ !9x5-- @ !xn-- @ !xn-- @ !xV-- @ !=xW-- @ !x-- @ !x4-- @ !xn-- @ !xV-- @ !x-,n5---  2 ;5n ',Vn--- 2 t nVTo Where? --- 2 nV ',W---  2 ]W '- @ !4-- @ !95-- @ !n-- @ !n-- @ !V-- @ !=W-- @ !-- @ !4-- @ !n-- @ !V-- @ !- - @ !5-   - @ !-  ,5 - @ !S;-  --- 2 , 5INTAKE/OUTPUT   --- 2 5 '- @ !4-- @ !95-- @ !n-- @ !n-- @ !V-- @ !=W-- @ !-- @ !4-- @ !-,5--- 2 5TIME  --- 2 5 ',--- 2 2 LIQUID INTAKE   --- 2  ',--- 2  URINE OUTPUT    --- 2 c '- @ !4-- @ !5-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !4-- @ !-- @ !-- @ !-,5---  2 ;5 ',---  2  ',---  2  '- @ !4-- @ !5-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !4-- @ !-- @ !-- @ !-,5---  2 ;5 ',---  2  ',---  2  '- @ !4-- @ !5-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !4-- @ !-- @ !-- @ !-,5---  2 ;5 ',---  2  ',---  2  '- @ !4-- @ !5-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !4-- @ !-- @ !-- @ !-,5---  2 ;5 ',---  2  ',---  2  '- @ !4-- @ !5-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !4-- @ !-- @ !-- @ !-, 5---  2 ;5  ', ---  2   ', ---  2   '- @ !4-- @ !5-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !4-- @ !-- @ !-- @ !-, 5---  2 ;5  ', ---  2   ', ---  2   '- @ ! 4-- @ ! 5-- @ ! -- @ ! -- @ ! -- @ ! -- @ ! -- @ ! 4-- @ ! -- @ ! -- @ ! -,)5---  2 &;5) ',)---  2 &) ',)---  2 &) '- @ !4-- @ !5-- @ !-- @ !-- @ !-- @ !-- @ !-- @ !4-- @ !-- @ !-- @ !-,8*5---  2 5;5*8 ',8*---  2 5*8 ',8*---  2 5*8 '- @ !)4-- @ !)5-- @ !)-- @ !)-- @ !)-- @ !)-- @ !)-- @ !*4-- @ !*-- @ !*-- @ !*-,I95--- 2 F59ITOTALN  --- 2 F59I ',I9---  2 E9I ',I9---  2 E9I '- @ !84-- @ !85-- @ !8-- @ !8-- @ !8-- @ !8-- @ !8-- @ !94-- @ !I4-- @ !I4-- @ !I5-- @ !9-- @ !I-- @ !I-- @ !9-- @ !I-- @ !I-- @ !9-- @ !I-- @ !I----  2 U; --՜.+,0 hp   Department of Veterans Affairs   Volunteer Checklist Volunteer ChecklistR RN__________________ Volunteer_________________ Date__________ Time__________J Patients Name __________________ Last 4 SS# __________ DOB _________ Title Headings  !"#$%&'()*+,-/012345678:;<=>?@ABCDEFGHJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^`abcdefkRoot Entry FAemData .1Table9WordDocument0ZSummaryInformation(I+DocumentSummaryInformation8_CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q