Patient Name: ________________________________ Date of Implant: ________________ Patient/Pump Data Baseline Parameters Date: Time Weight Temperature Blood Pressure Heart Rate Pump Flow (LPM) Pump Speed (RPM) Pump Power (Watts) Y Y Y Y Y Y Y Alarms N N N N N N N Y Y Y Y Y Y Y Exit Site Dressing Change N N N N N N N Exit Site Clean/Dry (Please describe any drainage, swelling, inflammation, redness, pain or other changes from baseline) Pain: No Other: Blood Thinning Medications Aspirin Dose Other: INR Anticoagulation Medication:___________ Other: For any emergency (for example, pump stop, loss of power to the pump, broken wires, damage to the pump motor or system controller, and/or change in health, etc), please call _____________________________________________________________
Patient Name: ________________________________ Date of Implant: ________________ Patient/Pump Data Baseline Parameters Date: Time Weight Temperature Blood Pressure Heart Rate Pump Flow (LPM) Pump Speed (RPM) Pump Power (Watts) Alarms Y N Y N Y N Y N Y N Y N Y N Exit Site Dressing Change Y N Y N Y N Y N Y N Y N Y N Exit Site (Please describe any drainage, swelling, inflammation, redness, pain or other changes from baseline) Clean/Dry Pain: No Other: Blood Thinning Medications Aspirin Dose Other: INR Anticoagulation Medication:___________ Other: For any emergency (for example, pump stop, loss of power to the pump, broken wires, damage to the pump motor or system controller, and/or change in health, etc), please call _____________________________________________________________
gl1101_rev01_patient_home_record_patient_discharge_folder_11.14.docx