Sample Flow Sheet Template printable pdf download

Sample Flow Sheet Template

SAMPLE FLOW SHEET

Please note: Flow sheets are intended to allow CRU personnel to effectively perform and document

study procedures. The examples here are only a guide. Your specific study will require appropriate

modifications. Inpatient and outpatient flow sheets may differ. Flow sheets must reflect study orders.

Please leave space that is appropriate to record results. For assistance in establishing/finalizing flow

sheets, please contact the CRU Nurse-Manager, Margaret Garrett-Herry, MSN, FNP (241-1515).

Study Name:

Patient Study ID:

GCO#:

PI:

Co-I:

Research Coordinator: _____________________

Date: _______

Time: _______

Allergies: ____________________________

Study visit:

(circle one)

& HIPPA



ONFIRM SIGNED CONSENT

FORM

VS: BP______ P______ T_______ R_______



(and q 6hrs while awake; use CRU supplementary VS flow sheet)

Wt _______(kg)



NP (

)



HYSICAL EXAMINATION COMPLETED BY STUDY PHYSICIAN OR

SEPARATE FORM



EKG done



Urine specimens done

U/A

U-tox.

Other_______

(please circle)

Urine pregnancy test

positive

negative



(please circle)



After cleansing with alcohol, blood specimens drawn with _____gauge angiocatheter to saline lock ______ via

______vein with/ without difficulty. (List IVF if applicable)

The following specimens drawn:



 CBC w/diff & plts and Reticulocyte count (send to MSH labs)

 7 ml Red top (label “pre dose” and hold for study coordinator)

Time: __________ Administer study drug



Serve Breakfast



 Blood collection (via IV) 2 hours post-drug administration, 7 ml RED TOP (label “post dose”

and hold for study coordinator)

D/C IV



Discharge to ____________________ @ Time: __________



RN Signature:____________________________________

*Allergies must be listed

Sample Flow Sheet Template

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