Patient Care – Empty Client Charts

Daily Assessment Record

Legend:X= YesDate:__________________________
SystemNormal CriteriaFormNotes
Safety:QPA ☐Bedside Safety ☐Falls Risk Assessment ☐15 min checks ☐
Neurological/ Cognition:Alert & orientated x 3, speech clear and understandable, memory intact, active ROM, sensation intact, no paresthesia ☐Delirium Screening ☐
Neuro Vitals ☐
Cardiovascular:Regular apical/peripheral pulse, no chest pain, peripheral pulses palpable, no calf redness, extremities pink and warm ☐Telemetry Monitoring ☐ Vascular Form ☐
Respiratory:Resting respirations quiet & regular, symmetrical chest wall movement, pink nail beds and mucous membranes, air entry clear to bases on L&R lobe ☐Chest ☐
Tube ☐
Suction ☐
Trach ☐
GastrointestinalAbdomen soft and non distended, tolerates without nausea, no difficulty swallowing, bowel pattern normal for pt, bowel sounds present ☐Last BM ____________
Parenteral Nutrition ☐
Enteral Nutrition ☐
Ostomy ☐
Tube ___________________
Genitourinary:Urinates without pain, voiding pattern is usual, urine clear, yellow ☐Urostomy ☐
Foley ☐
Gynecology/UrologySkin intact ☐, no lesions or discharge ☐, no itch or odor ☐STI Screening ☐
LMP ____________
Musculoskeletal:Steady gait, no fractures/sprains/strains ☐Total Care ☐
1Person Assist ☐
2Person Assist ☐
Psychosocial:Interacts and communicates in an appropriate manner with others, demonstrates effective coping skills ☐MSE ☐
Integumentary:Color normal, warm, dry and intact, moist mucus membranes ☐Braden ☐
Wound Care ☐
Drain_____________
Pain:Denies pain ☐Pain assessment ☐
Other:
IV:Free inflammation, patent, no pain, dressing intact, flushes well ☐Type_______
Gauge_______
Location_________
Lumen #____________
DateNurses Notes (Data/Action/Response/Notes)Provider

Vital Signs

DAY
TIME
TEMPERATURE
PULSE
RESPIRATION
BLOOD
PRESSURE
O2 SAT
WEIGHT
Initials
DAY
TIME
TEMPERATURE
PULSE
RESPIRATION
BLOOD PRESSURE
O2 SAT
Weight
Initials
DAY
TIME
TEMPERATURE
PULSE
RESPIRATION
BLOOD PRESSURE
O2 SAT
Weight
Initials

SBAR Report

SBAR Hand-offCurrent Day/Time:Admission Day/Time:
SituationPatient Name:
Age:Gender:
Provider:
Admission Diagnosis and Current Problem/Issue:
BackgroundPertinent Medical History:
Pertinent Social History:
Allergies:
Code Status:
Vital Signs:
(Most recent)
Time:BP:RR:
Temp:Pulse:SpO2:
Oxygen Therapy:Mode:LPM:
Pain:Rating:Most recent Pain Medication:
Time:
Other recent medication:
IVs:#TypeSite:AssessmentFluid
Drains and Tubes:Site:Type:Assessment:
Wounds:Site:Type:Assessment:
ADLs:Diet:Activity:
Restrictions:Isolation:Fall Risk:
Assessments:Neurologic
Cardiac:
Respiratory:
GI/GU:
Integumentary:
Ortho/Mobility:
Psychosocial:
Other:
Labs & Diagnostics:
AssessmentNurse’s Assessment:
RecommendationPlan of Care:
Tests/Results Pending:
Orders Pending Completion:
Other:
Nurse Completing Form:

Wound Care (WIP)

Wound Type/Etiology (if known)
Pressure ☐            Venous ☐               Arterial ☐                Diabetic ☐               Surgical 2°Intent ☐             Skin Tear ☐            Other ☐
If Pressure Ulcer, chart stage: Stage 1_________        Stage 2_________            Stage3_________         Stage 4_________                                       Stage X(unstageable)_________                   Stage SDTI (Suspected Deep Tissue Injury)_________      
                                                                                                                                                                                                            
MARK LOCATION OF WOUND/ULCER WITH AN ARROW OR AN ”X”
Legend: X or Blank Space = Not Applicable (as per agency)     I    * = Assessed/Completed  I    PN = See Progress Notes
Wound Location:Date:Date:
Time:Time:
Measurements
Length
Width
Depth
Sinus Tract #1 Depth
Location (o’clock)
Sinus Tract #2 Depth
Location (o’clock)
Undermining #1 Depth
Location (o’clock)
Undermining #2 Depth
Location (o’clock)
Wound Bed:
Total % must =
100%
% Pink/Red
% Granulation (red pebbly)
% Slough
% Eschar
% Foreign body (sutures, mesh, hardware)
% Underlying structures (fascia, tendon, bone)
% Not visible
% Other:
Exudate Amount
None
Scant/small
Moderate
Large/copious
Exudate Type
Serous
Sanguineous
Purulent
Other:
OdorOdour present after cleansing Yes or No
Wound EdgeAttached (flush w/ wound bed or ”sloping edge”)
Non-Attached (edge appears as a ”cliff”)
Rolled (curled under)
Epithelialization
Peri-wound SkinIntact
Erythema (reddened) in cm
Indurated (firmness around wound) in cm
Macerated (white, waterlogged)
Excoriated/Denuded (superficial loss of tissue)
Callused
Fragile
Other:
Wound Pain
(10 = worst)
Scored from 10 point analogue Pain Scale
See Pain Assessment for details
TreatmentIf packing used, indicate # of packing pieces out/inOut= _____ In=_____Out= _____ In=_____
Treatment Plan                                                                        
 Date Initiated:
Plan:
Date D/C:
Date Initiated:
Plan:

Mental Status Exam

Date
Time
Mental Status Exam (MSE)Notes Required
General Appearance:
Age
Hygiene/Grooming
Build


☐ Appears stated age ☐ Appears younger than age ☐ Appears older than age
☐ Clean ☐ Body odor ☐ Tattoos ☐ Dressed appropriately to season ☐ Unkempt
☐ Average ☐ Frail ☐ Obese ☐ Muscular ☐ Petite ☐ Stocky
Behavior:
Eye contact
Attitude
LOC
Activity Level
Posture

☐ Poor ☐ Adequate ☐ Good ☐ Intense ☐ Engaging ☐ Disengaged
☐ Cooperative ☐ Guarded ☐ Open ☐ Fearful ☐ Demanding ☐ Defensive ☐ Suspicious
☐ Alert ☐ Confused ☐ Sedated/drowsy ☐ Hyper alert ☐ Fluctuating
☐ Normal ☐ Pacing ☐ Posturing ☐ Apraxia ☐ Wringing hands ☐ Wandering
☐ Relaxed ☐ Rigid ☐ Slumped ☐ Erect
Mood: (reported by client)☐ Afraid ☐ Angry ☐ Anxious ☐ Depressed ☐ Energetic ☐ ☐ Frustrated ☐ Happy
☐ Upset ☐ Overwhelmed ☐ Lonely ☐ Worried ☐ Normal
Affect:

Stability/Range
Congruency
☐Angry ☐ Depressed ☐ Anxious ☐ Euphoric ☐ Fearful ☐ Irritable ☐ Suspicious ☐ Euthymic
☐ Labile ☐ Blunted ☐ Flat ☐ Full ☐ Range
Is Affect congruent with content of speech and circumstances? ☐ Yes ☐ No
Risk: Suicide Risk









Prior Suicide Behavior



Level of risk to client
Safety Plan completed?
Homicidal Ideation
Ideation: ☐ Yes ☐ No ☐ Unknown Plan: ☐ Yes ☐ No ☐ Unknown


Resources: ☐ Yes ☐ No ☐ Unknown Means: ☐ Yes ☐ No ☐ Unknown


Distress/Pain: ☐ Yes ☐ No ☐ Unknown Triggers: Yes No Unknown


Lost someone close to suicide: ☐ Yes ☐ No ☐ Unknown
☐ Yes ☐ No ☐ Unknown Details:
Has patient made a suicide attempt or engaged in significant intentional self-harm behaviour within the
past 24 hours? ☐ Yes ☐ No ☐ Unknown Comments:
(observed by clinician) ☐ None ☐ Mild ☐ Moderate ☐ High/Imminent
☐ Yes ☐ No Details
☐ Yes ☐ No ☐ Unknown Details:
Thought Process:☐ Disorganized ☐ Normal ☐ Spontaneous ☐ Poverty ☐ Thought Blocking ☐ Vague
☐ Logical ☐ Perseverative
Speech: Amount
Rate
Pressure
Associations
Rhythm
☐ Normal ☐ Mute ☐ Monosyllabic Clarity: ☐ Clear ☐ Incoherent ☐ Slurred
☐ Normal ☐ Controlled ☐ Slowed ☐ Rapid Volume: ☐ Loud ☐ Moderate ☐ Soft
☐ Normal ☐ Low ☐ Pressured ☐ Explosive
☐ Normal ☐ Loose ☐ Flight of ideas ☐ Word Salad ☐ Tangential
☐ Normal ☐ Even ☐ Hesitant ☐ Stuttering
Thought Content:
Delusions


Unusual content
???
☐ Compulsion ☐ Depressive ☐ Risk to self/others ☐ Thoughts about future
☐ Control ☐ Somatic ☐ Mind reading ☐ Persecution ☐ Grandiosity ☐ Thought broadcasting
☐ Obsessions ☐ Phobias ☐ Preoccupations ☐ Ruminations
☐ Congruent to situation
Perceptual Abnormalities:
Hallucinations

☐ Depersonalization ☐ De-realization ☐ Illusions ☐ None observed
☐ Auditory (command) ☐ Auditory (non-command) ☐ Visual ☐ Denies
Cognition: Memory
Attention
Orientation
Concentration
☐ Intact ☐ Deficits
☐ Good ☐ Mildly distracts ☐ Unable to attend
☐ Person ☐ Place ☐ Time
☐ Good ☐ Fair ☐ Poor
Insight
Reasoning/Judgement
☐ Full ☐ Partial ☐ Limited ☐ Minimal ☐ Absent
☐ Intact ☐ Mild impairment ☐ Moderate impairment
☐ Severe impairment
Notes:

In/Out Record

INTAKEDATE24 Hr Total
SHIFT:DaysNights
TIME:
ORAL
IV
TUBE FEED
BLOOD
TPN
LIPIDS
Other
TOTAL
OUTPUTDATE
TIME:
VOID
FOLEY
EMESIS
Other:
STOOL
TOTAL
24 hr
Balance

Blood Glucose Record

BreakfastLunchDinnerHS
Date:
Time:
Reading:
Comments:
Date:
Time:
Reading:
Comments:

Braden Scale

DATE/TIME OF ASSESSMENT:
Sensory perception
Ability to respond meaningfully to pressure-related discomfort
1. Completely limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation,
OR

Limited ability to feel pain over most of body surface
2. Very limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness,
OR

Has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body.
3. Slightly limited: Responds to verbal commands but cannot always communicate discomfort or need to be turned,
OR
Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
4. No impairment: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.
Moisture
Degree to which skin is exposed to moisture
1. Constantly moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.2. Moist: Skin is often but not always moist. Linen must be changed at least once a shift.3. Occasionally moist: Skin is occasionally moist, requiring an extra linen change approximately once a day.4. Rarely moist: Skin is usually dry; linen requires changing only at routine intervals.
Activity
Degree of physical activity
1. Bedfast: Confined to bed.2. Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.3. Walks occasionally: Walks occasionally during day but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.4. Walks frequently: Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.
Mobility
Ability to change and control body position
1. Completely Immobile: Does not make even slight changes in body or extremity position without assistance.2. Very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.3. Slightly limited: Makes frequent though slight changes in body extremity position independently.4. No limitations: Makes major and frequent changes in position without assistance.
Nutrition
Usual food intake pattern
1. Very poor: Never eats a complete meal. Rarely eats more than ⅓ of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement,
OR

Is NPO1 and/or maintained on clear liquids or IV2 for more than 5 days.
2. Probably Inadequate: Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement,
OR

Receives less than optimum amount of liquid diet or tube feeding.
3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement of offered,
OR

Is on a tube feeding or TPN3 regimen, which probably meets most of nutritional needs.
4. Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
Friction and Shear1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequent slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction.2. Potential problem: Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.3. No apparent problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in be or chair at all times.
TOTAL SCORE:
SignatureInitials

Falls Risk Assessment

RISK FACTOR PRESENTSTRATEGIES
More than 2 falls in previous 6 months
Move in facility in the past month
Dates of falls:

Safety awareness:
Attempts to unsafely TRANSFER or WALK
Not following instructions, agitation, restlessness
☐ Yes ☐ No
☐ Yes ☐ No


☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
Review history of falls from fall reports
☐ Hip protectors
☐ Fall mat in place
☐ Bed in low position for person’s height
☐ Lower rails down
☐ Use of mobility aid within reach with brakes on
☐ Head protectors
Orthostatic hypotension, hypertension/vertigo
Check difference in Stood Pressure

Date:
Lying: ______________________________________
Sitting:______________________________________
☐ Yes ☐ No
__________
☐ Educate resident on how to best transfer and change position when appropriate
☐ Refer to Pharmacist, Physician & other members of the interdisciplinary
Cognitive alterations: (e.g., delirium,
acquired brain injury, dementia, mental health disorders, infection)
Mood alteration such as depression, agitation
☐ Yes ☐ No☐ Develop Care Plan to support residents routines and preferences
☐ Utilize bed/chair check, movement alarm, resident wandering system, or motion detector
Impaired mobility, balance or gait☐ Yes ☐ NoAssess for
☐ Proper shoes, non slip socks for night use
☐ Appropriate walking aid, hip protectors
☐ Refer to PT/OT for exercises, seating, etc.
Generalized weakness
What is the ambulation ability? ___________________________________
What is the transfer ability? ______________________________________
What is the bed mobilty? ________________________________________
What is the nutrition risk? ________________________________________
☐ Yes ☐ No☐ Refer to PT/OT
☐ Safe Transfer _____________
Bed Mobility ________________
☐ Pain ____________________
☐ Refer to RD (if poor intake and significant weight loss)
Visual/Perceptual deficits☐ Yes ☐ NoAssess for
☐ Declutter the room
☐ Refer to Optometrist
☐ Provide sufficient lighting in the room/hallway
Urinary and bowel elimination – urgency & frequency☐ Yes ☐ No☐ Review Voiding Record/Bowel Record to establish regular bladder/bowel routine
☐ Ensure the client is able to safely toilet self or have care team follow the routine
Medication and substance use:
☐ Antidepressants ☐ Antihypertensive
☐ Alcohol ☐ Benzodiazepine
☐ Anagesics/Opiods ☐ Diabetic medications
☐ Antipsychotics ☐ Poly pharmacy
☐ Sedatives/Hypnotics
☐ Yes ☐ No☐ Ensure Medications are appropriate – dosage and medication form are easily taken
☐ Consult with Pharmacist or Physician
☐ Medication review done

Similar Posts