Resident initials ________Room number______
Elimination:
Age _____________ Gender _______________
Incontinent? Y N if yes, Bowel Bladder Both
Allergies ________________________________
Date of last BM __________________________
Output for shift __________________________
Code Status _____________________________
Vital signs:
Time ______________________
T _________________ R __________________
BP ________________ P __________________
O2 _____________ Delivery method _________
Pain Assessment:
O _____________________________________
L ______________________________________
D _____________________________________
Assessment:
Neuro/mental status: Alert? ________________
Oriented to:
Person
Place
Time
HEENT: Eyes (glasses?)____________________
Hearing _________Mouth (dentures?)________
Skin: ___________________________________
Heart: Apical pulse rate__________________
Regular or irregular_______________________
C _____________________________________
Lungs: Lung sounds and location(s) __________
A _____________________________________
_______________________________________
R _____________________________________
Abdomen: Bowel sounds___________________
T _____________________________________
Peripheral extremities:
S ______________________________________
M___________________V_________________
Mobility:
P____________________N_________________
Ordered activity level_____________________
H____________________L_________________
Assistance needed #______________________
C____________________E_________________
T____________________CR________________
Assistive devices _________________________
PT or OT? _______________________________
Additional notes:
Nutrition:
_______________________________________
Diet ___________________________________
_______________________________________
Assistance needed________________________
_______________________________________
_______________________________________
Intake: Total fluids (in mL)__________________
_______________________________________
Breakfast % __________ Lunch % ___________
_______________________________________