Healthcare IMV Report

HEALTHCARE IMV REPORT

Patient & Administrative Information

Facility Name:    Department/Unit:

Report Prepared By:    Report Date:

Date of Birth:    Gender: Male Female Other

Phone:    Medical Record No.:    Admission Date:

Insurance Information

Policy Number:    Group Number:    Subscriber Name:

Clinical Indication & History

Ventilator Details & Settings

IMV Initiation Date/Time:    Device Make/Model:

Assist Control (AC)    SIMV    Pressure Support    CPAP    Other:

Tidal Volume:    Set RR:    FiO2:    PEEP:

Physiologic Measurements & Laboratory Data

Most Recent ABG Date/Time:

pH:    PaCO2:    PaO2:    HCO3-:    SaO2:

Sedation / Paralysis

Neuromuscular Blockade in Use: Yes    No    If yes, agent/dose:

Complications, Events & Safety Checks

Ventilator-associated pneumonia suspected    Barotrauma (pneumothorax)    Unplanned extubation    Hemodynamic instability    Other:

Weaning Assessment & Plan

Spontaneous Breathing Trial Attempted: Yes    No    If attempted, outcome:

Authorization, Certification & Privacy Acknowledgment

I certify that the clinical data recorded in this IMV Report are true and complete to the best of my knowledge. This report may be used by the multidisciplinary care team for ongoing patient management and relevant quality review. I understand that the information contained herein is subject to applicable privacy and confidentiality protections.

Patient/Representative acknowledges receipt of ventilator summary and care plan summary and consents to sharing this information with other treating providers as necessary for care coordination:    Acknowledged

Authorization Expiration Date:

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