| Assess./Interv. | Day 1 |
|---|---|
| Vital Signs | |
| Blood Pressure (mmHg) |
120/80
130/90
135/88
140/95
180/110
|
| Temperature (°F/°C) |
.
|
| Heart Rate (bpm) |
60
70
78
90
100
|
| Respiratory Rate (rpm) |
12
16
20
24
|
| O2 Saturation (%) |
94
95
98
100
|
| Neurological (WDL) | |
| Level of Consciousness |
Alert
Lethargic
Obtunded
Unresponsive
|
| Orientation Level (x1–x4) |
x1
x2
x3
x4
|
| Cognition |
Intact
Mildly impaired
Severely impaired
|
| Speech |
Clear
Slurred
Aphasic
|
| Eye Movement R/L |
Normal
Nystagmus
Limited
|
| Pupil Size R/L | |
| Pupil Reactivity |
Brisk
Sluggish
Fixed
|
| Extremity Movement RUE/LUE/RLE/LLE |
Normal
Weak
Paralysis
|
| GCS Score | |
| Sedation Scale (RASS) |
-5
-4
-3
-2
-1
0
+1
+2
+3
+4
|
| HEENT (WDL) | |
| Head and Face |
Symmetrical
Asymmetrical
|
| Eyes (R/L) |
Conjunctiva
Sclera
Drainage noted
PERRLA
|
| Ears (R/L) |
Drainage
Hearing intact
Impaired
|
| Nose |
Midline
Deviation
Drainage
|
| Lips |
Moist
Dry
Cracked
|
| Throat |
Redness
Swelling
Normal
|
| Tongue |
Normal
Coated
Swollen
|
| Voice |
Clear
Hoarse
Aphasic
|
| Mucous Membranes |
Moist
Dry
|
| Teeth |
Dentures
Natural
Missing
|
| Neck |
Supple
Stiff
Swollen
|
| HEENT Interventions - Eye Care | |
| HEENT Interventions - Oral Hygiene | |
| Respiratory (WDL) | |
| Respiratory Pattern |
Regular
Irregular
|
| Depth/Rhythm |
Normal
Shallow
Deep
|
| Effort |
Unlabored
Labored
Use of accessory muscles
|
| Characteristics |
Wheezing
Rales
Rhonchi
Clear
|
| Chest Assessment |
Symmetrical rise
Retractions
Barrel chest
|
| O2 Administered |
Yes
No
|
| Suctioning | |
| Cardiac | |
| Heart Sounds |
S1 S2 Present
Murmurs
Gallops
Rubs
|
| Jugular Venous Distension |
Present
Absent
|
| Cardiac Rhythm |
NSR
Afib
PVCs
Tachycardia
Bradycardia
|
| Ectopy |
Present
Absent
|
| Telemetry Monitor Status |
On
Off
|
| Alarms |
On
Off
Parameters documented
|
| Box Number | |
| Audible |
Yes
No
|
| Pacemaker |
Yes
No
|
| Pacemaker Type |
Atrial
Ventricular
Dual chamber
|
| Peripheral Vascular (WDL) | |
| Pulses R/L (Radial, Pedal, Posterior Tibial) |
Present
Diminished
Absent
|
| Capillary Refill |
<2s
>2s
|
| Edema |
None
+1 to +4
Pitting
Non-pitting
|
| Skin Color & Temp |
Pink
Pale
Cyanotic
Cool
Warm
|
| Integumentary (WDL) | |
| Skin Color | |
| Skin Temp | |
| Skin Integrity |
Intact
Breakdown
Rash
|
| Skin Turgor | |
| Wound Observations (if any) | |
| Braden Scale | |
| Sensory Perception |
1
2
3
4
|
| Moisture |
1
2
3
4
|
| Activity |
1
2
3
4
|
| Mobility |
1
2
3
4
|
| Nutrition |
1
2
3
4
|
| Friction and Shear |
1
2
3
|
| Braden Total Score | |
| Musculoskeletal (WDL) | |
| RUE / LUE / RLE / LLE |
Full movement
Limited
Contracture
|
| Gait |
Steady
Unsteady
Assisted
|
| Muscle Strength |
0
1
2
3
4
5
|
| Joint Deformities | |
| Assistive Devices in Use | |
| Gastrointestinal (WDL) | |
| Abdominal Inspection |
Flat
Distended
Obese
|
| Bowel Sounds (All Quads, RUQ, RLQ) |
Active
Hypoactive
Absent
|
| Tenderness |
Soft
Non-distended
Tender
|
| Last BM Date | |
| Passing Flatus |
Yes
No
|
| Bowel Incontinence |
Yes
No
|
| Stool Color / Appearance | |
| Nausea |
Yes
No
Frequency
|
| Emesis Characteristics | |
| Constipation/Precipitating Factors | |
| GI Interventions | |
| Genitourinary (WDL) | |
| Urinary Incontinence |
Yes
No
|
| Urine Color | |
| Urine Appearance | |
| Urine Odor | |
| Suprapubic Tenderness |
Yes
No
|
| Genitalia Observations | |
| Urinary Catheter Present | |
| GU Interventions | |
| Psychosocial (WDL) | |
| Behavior |
Calm
Agitated
Withdrawn
|
| Support System Present |
Yes
No
|
| Interaction with Staff |
Cooperative
Anxious
|
| Interventions |
Chaplaincy
Counseling
Social Work
|
| Provider Notification | |
| Reason for Communication |
VS Change
New Symptoms
Family Concern
|
| Time Notified | |
| Provider Response | |
| Pain Assessment | |
| Pain Score (0-10) |
0
3
5
7
10
|
| Location / Quality | |
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 |
Recent Notes
03/21/2025 – Progress Note: Pt stable, mild ankle edema...
Imaging
03/20/2025 – CXR: mild cardiomegaly, RLL infiltration suspected.
| Medication | Day 1 | Day 2 | Day 3 | Day 4 | Day 5 |
|---|---|---|---|---|---|
| NS IV @ 75 mL/hr Continuous Infusion |
Running 75 |
Running 75 |
Running 75 |
Running 75 |
Running 75 |
| Lisinopril 10mg PO Daily |
Due | Due | |||
| Tylenol 650mg PO PRN Q4H |
10:15 RN |
22:05 RN |
|||
| Metformin 500mg PO BID |
Due | Due | |||
| Hydrocodone-APAP 5-325mg PRN Q6H |
Due |