Weekly Inventory Form - CNY Infusion Services

Patient Name*

First Last

Current Patient Weight (Lbs)*

Any Medication changes?*

Yes

No

(new medications, stopped medications)?

If so, please list medication changes here:*

Any administration issues?*

Yes

No

(PICC, PORT, G-tube, J-tube, other)?

If so, please describe them here:*

Any issues with equipment supplied by CNY infusion?*

Yes

No

If so, please describe them here:*

Any Questions/Comments?

Additional Questions for IV Therapy

Drug Name(s)

When was the last dose of IV medication given?

How many does of IV medication do you have remaining?

Saline Syringes

How many do you have?

How many do you use per day?

Heparin Syringes

How many do you have?

How many do you use per day?

Injekt Syringes (for nurse blood draw) – How many do you have?

10mL Syringe with Needle – how many do you have?

Alcohol pads – how many boxes do you have?

Tape ½” cloth – how many rolls do you have?

How many C batteries do you have remaining?

Tubing for medication

How many do you have?

When is tubing due to be changed next? (Date)

When is tubing due to be changed next? (Time)

:

Sterile covers (to cap tubing when not in use) – how many do you have?

Dressing change kit (PICC/PORT/IV line)

How many do you have?

When was the PICC/PORT/IV line dressing last changed? (Date)

When was the PICC/PORT/IV line dressing last changed? (Time)

:

Caresites with attached extension tubing – how many do you have?

Grip-Lok / Statlock (PICC/IV securement device) – how many do you have?

Aegis Antimicrobial disc – how many do you have?

Huber needle (for PORT) – how many do you have?

Additional Questions for Tube Feeding / Enteral Therapy

How many cans/cartons per day are you using?

How many cans/cartons do you have?

Kangaroo Joey Pump Bags – how many do you have?

Syringe 60mL catheter tip – how many do you have?

Comments

Weekly Inventory List Update

Additional Questions for IV Therapy

Additional Questions for Tube Feeding / Enteral Therapy

Administrative Office

Office Hours

Contact