* = Required Information
Vitals
Reg Irreg

SN SN & Supervisory Supervisory Only
Denote Location / Size of Wounds / Pressure Sores / Measure Ext. Edema Bil.
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Needs assistance for all activities Residual weakness
Requires assistance to ambulate Confusion, unable to go out of home alone
Unable to safely leave home unassisted Severe SOB, SOB upon exertion
Dependent upon adaptive device(s) Medical restrictions
Other

NURSING ASSESSMENT AND OBSERVATION SIGNS/SYMPTOMS
Fluid retention
Chest pain
Neck vein distension
Peripheral pulses

Edema Specify
RUE
RLE
LUE
LLE

Other
Burning
Distension/Retention
Frequency/Urgency
Hesitancy
Hematuria
Bladder incontinence
Catheter
Discharge
Diabetic urine testing
Discharge
Diabetic urine testing

Urine
Color
Consistency
Odor

Other
Balance/Unsteady gait
Weakness

Other
Neurosensory
Syncope
Headache
Tremors
Vertigo
Speech impairment
Hearing impairment
Visual impairment
Decreased sensitivity

Other
Grasp
Right
Left
Movement
RUE
RLE
LUE
LLE


Pupil reaction-
Right:

Left:

Color
Nausea/Vomiting
Anorexia
Epigastric distress
Difficulty swallowing
Abdominal distension
Colostomy
Diarrhea
Constipation/Impaction
Bowel incontinence
Other
Pain
Origin
Location
Duration
Intensity: (0-10)
Other
INTERVENTIONS/INSTRUCTIONS
Skilled observation & assessment Foley care
Urine testing Wound care/dressing
Decubitus care Venipuncture
Post-cataract care Bowel/Bladder training
Digital exam with manual removal/Enema Chest physio./Postural drainage
Change NG/G tube Admin. of vitamin B 12
Prep./Admin. insulin Teach/Admin. IVs/Clysis
Teach ostomy/ileo. conduit care Teach/Admin. tube feedings
Teach/Admin. care of trach. Teach/Admin. Inhalation Rx
Teach care - terminally ill IM injection
Psych. intervention Observe S/S infection
Diabetic observation Teach diabetic care
Observe/Teach medication (N or C) effects/side effects Physiology/Disease process teaching
Observe ADLs Evaluate diet/fluid intake
Diet teaching Safety factors
Prenatal assessment Post-partum assessment
Teach infant/child care Pain Management
Other
Reviewed/Revised with patient involvement
Outcome achieved
PRN order obtained
No change
Order obtained
Yes No N/A
Yes No
Physician PT
OT ST
SS SN
Other
Present Not present
Scheduled Unscheduled
Yes No