| Assessment / Intervention | Day 1 | Day 2 | Day 3 | Day 4 | Day 5 |
|---|---|---|---|---|---|
| Vital Signs | |||||
| Blood Pressure (mmHg) |
120/80
130/90
135/88
140/95
180/110
|
120/80
130/90
135/88
140/95
180/110
|
120/80
130/90
135/88
140/95
180/110
|
120/80
130/90
135/88
140/95
180/110
|
120/80
130/90
135/88
140/95
180/110
|
| Temperature (°F/°C) |
.
|
.
|
.
|
.
|
.
|
| Heart Rate (bpm) |
60
70
78
90
100
|
60
70
78
90
100
|
60
70
78
90
100
|
60
70
78
90
100
|
60
70
78
90
100
|
| Respiratory Rate (rpm) |
12
16
20
24
|
12
16
20
24
|
12
16
20
24
|
12
16
20
24
|
12
16
20
24
|
| O2 Saturation (%) |
94
95
98
100
|
94
95
98
100
|
94
95
98
100
|
94
95
98
100
|
94
95
98
100
|
| Neurological (WDL) | |||||
| Level of Consciousness |
Alert
Lethargic
Obtunded
Unresponsive
|
Alert
Lethargic
Obtunded
Unresponsive
|
Alert
Lethargic
Obtunded
Unresponsive
|
Alert
Lethargic
Obtunded
Unresponsive
|
Alert
Lethargic
Obtunded
Unresponsive
|
| Orientation Level (x1–x4) |
x1
x2
x3
x4
|
x1
x2
x3
x4
|
x1
x2
x3
x4
|
x1
x2
x3
x4
|
x1
x2
x3
x4
|
| Psychosocial (WDL) | |||||
| Behavior |
Calm
Agitated
Withdrawn
|
Calm
Agitated
Withdrawn
|
Calm Agitated Withdrawn |
Calm Agitated Withdrawn |
Calm Agitated Withdrawn |
| Provider Notification | |||||
| Reason for Communication |
VS Change
New Symptoms
Family Concern
|
VS Change
New Symptoms
Family Concern
|
VS Change New Symptoms Family Concern |
VS Change New Symptoms Family Concern |
VS Change New Symptoms Family Concern |
| Time Notified | |||||
| Provider Response | |||||
| Pain Assessment | |||||
| Pain Score (0-10) |
0
3
5
7
10
|
0
3
5
7
10
|
0
3
5
7
10
|
0
3
5
7
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 |