| Assessment / Intervention | 0700 | 1100 | 1500 | 1900 | 2300 |
|---|---|---|---|---|---|
| Vital Signs | |||||
| Blood Pressure | 120/80 | 130/90 |
135/88
120/80
130/90
135/88
140/95
|
142/92 |
120/80
130/90
135/88
140/95
|
| Heart Rate (bpm) | 78 | 80 | 85 | 90 |
82
72
78
82
90
|
| Temperature (°F) | 98.6 |
99.2
98.4
98.6
99.2
100.1
|
100.1 | 99.0 | 98.8 |
| Neurological (WDL) | |||||
| Level of Consciousness |
Alert
Alert
Lethargic
Obtunded
Unresponsive
|
Alert | Obtunded | Unresponsive | |
| Orientation Level |
x4
x1
x2
x3
x4
|
x3 | x2 | x4 | |
| Cognition |
Intact
Intact
Mildly impaired
Severely impaired
|
Intact | Mildly impaired | Severely impaired | |
| Speech | Clear | Slurred | Aphasic | Clear | |
| Eye Movement R/L | Normal | Nystagmus | Limited | Normal | |
| Pupil Size R/L (mm) | 3 / 3 | 4 / 4 | 3 / 2 | 2 / 2 | |
| Pupil Reactivity | Brisk | Sluggish | Fixed | Brisk | |
| Extremity Movement RUE/LUE/RLE/LLE | Normal | Weak | Normal | Paralysis | |
| GCS Score | 15 | 14 | 12 | 10 | |
| Sedation Scale (RASS) |
0 (Alert & Calm)
-5 (Unarousable)
-4 (Deep Sedation)
-3 (Moderate Sedation)
-2 (Light Sedation)
-1 (Drowsy)
0 (Alert & Calm)
+1 (Restless)
+2 (Agitated)
+3 (Very Agitated)
+4 (Combative)
|
-1 (Drowsy) | +1 (Restless) | -2 (Light Sedation) | |
| HEENT (WDL) | |||||
| Head and Face | Symmetrical | Asymmetrical | Symmetrical | ||
| Eyes (R/L) | Clear sclera | Drainage noted | Red conjunctiva | Normal | |
| Ears (R/L) | Normal | Hearing impaired | Drainage | Normal | |
| Nose | Midline | Drainage | Deviation | ||
| Lips | Moist | Dry | Cracked | ||
| Throat | Normal | Redness | Swelling | ||
| Tongue | Normal | Coated | Swollen | ||
| Voice | Clear | Hoarse | Aphasic | ||
| Mucous Membranes | Moist | Dry | |||
| Teeth | Dentures | Natural | Missing | ||
| Neck | Supple | Stiff | Swollen | ||
| Eye Care | Given | Not Needed | Scheduled | ||
| Oral Hygiene | Performed | Assisted | Refused | ||
| Respiratory (WDL) | |||||
| Respiratory Pattern | Regular | Irregular | Regular | ||
| Depth/Rhythm | Normal | Shallow | Deep | ||
| Effort | Unlabored | Labored | Accessory muscles | ||
| Breath Sounds | Clear | Wheezing | Rales | Rhonchi | Clear |
| Chest Assessment | Symmetrical rise | Retractions | Barrel chest | ||
| O2 Administered | Nasal Cannula 2 L | None | Mask 5 L | ||
| Suctioning | Oral Q4H | Nasal PRN | None | ||
| Cardiac | |||||
| Heart Sounds | S1 S2 Normal | Murmur | Rub | Gallop | |
| Jugular Venous Distension | Absent | Present | Absent | ||
| Cardiac Rhythm | NSR | AFib | PVCs | Tachy | |
| Ectopy | Absent | Present | Frequent | ||
| Telemetry Monitor Status | On, Alarms On | On, Alarms Off | Off | ||
| Pacemaker | None | Atrial | Ventricular | Dual Chamber | |
| Peripheral Vascular (WDL) | |||||
| Pulses (Radial, Pedal, PT) | All present | Diminished Pedal | Absent PT | ||
| Capillary Refill | <2s | >2s | <2s | ||
| Edema | None | +2 Pitting | +3 Pitting | ||
| Skin Color & Temp | Pink, Warm | Pale, Cool | Cyanotic, Cool | ||
| Integumentary (WDL) | |||||
| Skin Color | Normal | Pale | Reddened | ||
| Skin Temp | Warm | Cool | Hot | ||
| Skin Integrity | Intact | Breakdown | Rash | Wound Present | |
| Skin Turgor | Elastic | Tenting | |||
| Wound Observations | e.g. Sacral wound, Stage II, small serous drainage | ||||
| Braden Scale | Sensory: 4, Moisture: 3, Activity: 3, Mobility: 3, Nutrition: 4, Friction/Shear: 2 | Total: 19 (Auto-calc) | ||||
| Musculoskeletal (WDL) | |||||
| RUE / LUE / RLE / LLE | Full movement | Limited RUE | Contracture LLE | ||
| Gait | Steady | Unsteady | Assisted | ||
| Muscle Strength (0–5) | 5 | 4 | 3 | ||
| Joint Deformities | None | Arthritic changes | |||
| Assistive Devices | Cane | Walker | Crutches | ||
| Gastrointestinal (WDL) | |||||
| Abdominal Inspection | Flat | Distended | Obese | ||
| Bowel Sounds | Active (All quads) | Hypoactive RLQ | Absent LUQ | ||
| Tenderness | Soft, Non-distended | Tender RLQ | |||
| Last BM Date | 03/25 | 03/26 | 03/26 | ||
| Passing Flatus | Yes | No | |||
| Bowel Incontinence | No | Yes | Occasional | ||
| Stool Color / Appearance | Brown, Formed | Loose, Yellow | Black, Tarry | ||
| Nausea / Emesis | None | Nausea Q2H | Green vomit | ||
| GI Interventions | Antiemetic Given | Stool Softener | Enema | ||
| Genitourinary (WDL) | |||||
| Urinary Incontinence | No | Occasional | Frequent | ||
| Urine Color | Yellow | Dark Amber | Red-tinged | ||
| Urine Appearance | Clear | Cloudy | Sediment | ||
| Urine Odor | None | Foul | Strong | ||
| Suprapubic Tenderness | None | Present | |||
| Urinary Catheter Present | Foley 16Fr | Suprapubic | External | None | |
| GU Interventions | Catheter Care | Peri-care | Bag Change | ||
| Psychosocial (WDL) | |||||
| Behavior | Calm | Agitated | Withdrawn | ||
| Support System | Family Present | None | Friend Support | ||
| Interaction with Staff | Cooperative | Anxious | Hostile | ||
| Interventions | Chaplaincy Consult | Counseling | Social Work | ||
| Provider Notification | |||||
| Reason for Communication | VS Change | New Symptoms | Family Concern | ||
| Time Notified | 07:30 | 11:15 | |||
| Provider Response | Order Received | Awaiting Callback | |||
| Pain Assessment | |||||
| Pain Score (0-10) | 2 | 5 | 4 | 7 |
3
0
3
6
9
|
| Location / Quality | Lower back ache, mild throbbing | ||||
SnapShot
Demographics
Name: Panda Grayson
Age/Sex: 29 y/o M
Address: 77 Cherry Rd, Springfield
Phone: (555) 777-1212
Comm Pref: Email/Text
Problem List
1. Hypertension
2. Diabetes Type 2
3. Obesity
Tobacco History
Smoking Status: Ex-smoker
Smokeless Tobacco: Never
Vitals Trend
Last 24h: HR 70–90, BP 120/80–142/92, etc.
Chart Review
Latest Labs
| Lab Test | Value | Date/Time |
|---|---|---|
| Sodium | 140 mEq/L | 03/21/2025 03:07 |
| Potassium | 4.3 mEq/L | 03/21/2025 03:07 |
| WBC | 6.2 | 03/21/2025 03:07 |
| Creatinine | 1.0 mg/dL | 03/21/2025 03:07 |
| Glucose | 98 mg/dL | 03/21/2025 03:07 |
Recent Notes
03/21/2025 – Progress Note: Pt stable, mild ankle edema...
03/20/2025 – Admission Note: SOB, possible fluid overload, etc.
Imaging
03/20/2025 – CXR: mild cardiomegaly, RLL infiltration suspected.
Vitals Over Time
Last 3 days trend:
| Medication | 06:00 | 10:00 | 14:00 | 18:00 | 22:00 | 02:00 |
|---|---|---|---|---|---|---|
| Lisinopril 10mg PO Daily |
Due | Due | ||||
| Tylenol 650mg PO PRN Q4H |
10:15 RN |
22:05 RN |
||||
| NS IV @ 75 mL/hr Continuous Infusion |
Running 75 |
Running 75 |
Running 75 |
Running 75 |
Running 75 |
Running 75 |
| Metformin 500mg PO BID |
Due | Due | ||||
| Hydrocodone-Acetaminophen 5-325mg PO PRN Q6H |
Due |