1/3/14

Reusable Assessment Form (make photocopies for multiple Pts)

Reusable Assessment Form (make photocopies for multiple Pts)

1st

Name
Vital Signs Q:
Height:
Weight:
Room
1st Assess ____:____
Treatments / Current Status
Age Sex


Diagnosis


Code Status

Admit Date


History


Allergies


Primary

Attending
T
HR
RR
BP
SpO2 on Lungs
Pain
Tx/Result
Intake
Output
Diet / NPO / Clear / Full / ADA / AHA
CBG

Activity

Dressing

Foley

IV/Fluids

Teaching
Labs/Diagnostics
PRN

2ND

2nd Assess ___:___
Med/Treatment
Times >
Scheduled Medications/Treatments
T
HR
RR
BP
SpOon
Lungs
Pain
Tx / Result
Intake
Output

General Report (make copies for multiple Pts)

Name                                                                     Age                      Sex     Rm #
Diagnosis                                                                                           Code Status
Admit Date                                     Dr.
Surgery—Procedure
Neurological
Respiratory
CV
GI—GU
MS
Pain
Skin
Incision—Dressing
I & O
IVs                                                                         LTC
Diet—NPO
Activity
Labs—Procedures
Miscellaneous
D/C Planning—Teaching Needs

Assessment Notes (make copies for multiple Pts)

Use for exception-based charting or additional notes
Neuro

Respiratory

CV

GI

GU

MS

Pain

Skin


Exception-Based Charting is used to document exceptions or deviations from the norm as compared to previous assessments. Only the exceptions/deviations need to be documented. In most cases, a check mark (✓) indicates within normal limits, an arrow (⇐) indicates no change from previous assessment, and an
asterisk (*) indicates any deviation or change in status since the previous assessment. Any (*) needs to be clearly documented.

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