G ENERAL G ENERAL

Allergies:
Dx: Allergies:
Dx:
PMH:
Code: full / dnr / dni ♂ / ♀ Age: PMH:
Code: full / dnr / dni ♂ / ♀ Age:

Respirations: reg / irreg O2: L via Respirations: reg / irreg O2: L via

Skin: elastic / poor // warm / cold Color: Skin: elastic / poor // warm / cold Color:
Pulses: radial: strong / weak // L / R pedal: strong / weak // L / R Pulses: radial: strong / weak // L / R pedal: strong / weak // L / R
Mucous Membranes: pink / moist // dry / chapped Mucous Membranes: pink / moist // dry / chapped
Edema: 1+ / 2+ / 3+ / 4+ // pitting // L / R // U / L Edema: 1+ / 2+ / 3+ / 4+ // pitting // L / R // U / L
IV Site: L / R // dorsum / arm / __________________ _______________ IV Site: L / R // dorsum / arm / __________________ _______________
warm / cool // clean // edematous / red @ mL/° warm / cool // clean // edematous / red @ mL/°
Expires? pri-tubing / pri-bag / pb-tubing / ∆ Expires? pri-tubing / pri-bag / pb-tubing / ∆
In: In:
Out: Out:

Weight: kg / lb on Feeding: self / assist / total / tube: Weight: kg / lb on Feeding: self / assist / total / tube:
Dentures? yes / no Diet: normal / soft / diabetic / ↓-Na / Dentures? yes / no Diet: normal / soft / diabetic / ↓-Na /

Sounds: active / hyper / hypo // x Flatus? yes / no Sounds: active / hyper / hypo // x Flatus? yes / no

Ostomy: red // Clots? no / yes: Ostomy: red // Clots? no / yes:

ADLs: self / partial / total // assist x Tone: good / poor / flaccid ADLs: self / partial / total // assist x Tone: good / poor / flaccid
Activity: bed / BRP / ad lib / Devices: walker / w/c / Activity: bed / BRP / ad lib / Devices: walker / w/c /

LOC: A / drowsy / asleep // O x Language: English / LOC: A / drowsy / asleep // O x Language: English /

Xfer: stable / unstable // assist x
Amb: stable / w/c / walker / assist x
Vision: good / poor / blind
glasses / contacts
DEVELOPMENTAL
Fall Risk? yes / no
Hearing: good / hoh / deaf // L / R
Skin: dry / diaphoretic /
Xfer: stable / unstable // assist x
Amb: stable / w/c / walker / assist x
Vision: good / poor / blind //
glasses / contacts
DEVELOPMENTAL
Fall Risk? yes / no
Skin: dry / diaphoretic /
Hearing: good / hoh / deaf // L / R

HEALTH DEVIATION HEALTH DEVIATION

REPORT/NOTES REPORT/NOTES

Vitals : : report;  meds; vs; “participated” report;  meds; vs; “participated” Vitals  :  :
15-16
T: o / ax / r assess; assess; T: o / ax / r
16-17
P: ap / b / r P: ap / b / r
R: reg / irreg 17-18 R: reg / irreg
BP: L / R // a / l 18-19 BP: L / R // a / l
: faces / flacc vs; vs; : faces / flacc
19-20
SpO2: ra / O2 SpO2: ra / O2
;  I&O; report 20-21 ;  I&O; report
Pt: RN: RN: Pt:
Student Name: ___________________ Date of Care: __________
Rm: CNA: CNA: Rm: