JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Misallaneous
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First name-Last name
*
Your answer
First Name
*
Type in YOUR First Name
Your answer
Credential
*
Choose your credential
Choose
RRT/CRT
Respiratory Student
Other
Date/Time
*
Please select date of time of procedure
MM
/
DD
/
YYYY
Time
:
AM
PM
Verification
*
Did you verify with the Nurse and Order that the Art Line Draw was ordered on this patient?
Choose
Yes
No
PPE
*
Personal Protection Equipment. Did you use universal precautions, wash your hands, glove and wear eye protection for this procedure?
Choose
Yes
No
Treatment
*
Please describe treatment
Your answer
Assessment
*
Please chart pre/post assesment
Your answer
Conclusion
*
Please state if the treatment was affective and if the treatment should be continued or discontinued and the reason why
Your answer
Clean Up
*
Did you clean up the mess you made and assured the patient was safe?
Choose
Yes
No
Notify
*
Did you notify the nurse/M.D. of the results and an make the appropriate respiratory therapy changes?
Choose
Yes
No
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This form was created inside of weber.edu.
Report Abuse
Forms
