Admit: to service, location, team, physician responsible for the patient.
Diagnosis/discharge or disposition plans
Condition of the patient/code status
Vital signs with frequency
Allergies
Nursing instructions
Diet
Activity limitations
Laboratory test and radiographic studies
IV fluids, including composition and rate
I/O, including drains
Sedatives, analgesics, and other PRN mediciations
Medications, including dose, frequency, route, and indications. State "First dose now" when appropriate.
GI/DVT prophylaxis