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
SpO2 on
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.