| 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 | |||||
| Level of Consciousness |
Alert
Alert
Confused
Lethargic
|
Alert | Confused | Alert |
Alert
Confused
Lethargic
|
| Pupil Reaction (Brisk/Sluggish) | Brisk | Brisk | Sluggish | Brisk | Brisk |
| Cardiovascular | |||||
| Heart Rhythm | NSR | NSR | AFib |
PVCs/PACs
NSR
AFib
PVCs/PACs
|
NSR |
| Peripheral Pulses | Normal | Weak | Normal | Absent |
Bounding
Normal
Weak
Absent
|
| Respiratory | |||||
| Breath Sounds | Clear | Clear | Wheezes | Crackles | Clear |
| Respiratory Rate | 16 | 18 | 20 | 14 | 18 |
| Gastrointestinal | |||||
| Appetite | Good | Poor | Fair | Good |
Fair
Good
Fair
Poor
|
| Bowel Incontinence | No |
Yes
No
Yes
Occasional
|
No | Occasional | No |
| Genitourinary | |||||
| Voiding / Catheter | Voiding spontaneously | Foley | Difficulty | Voiding spontaneously | Foley |
| Skin | |||||
| Skin Integrity | Intact | Impaired | Intact | Wound Present |
Impaired
Intact
Impaired
Wound Present
|
| 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 |