Assessment & Plan Elements
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Resident admitted to facility with dx: [text name="_" size="10"]
Vital Signs: T [text size="4"]F, HR [text size="3"] bpm, [select name="HR" value="Regular, rate, rhythm|irregular|"], RR [text size="3"], BP [text size="3"]/[text size="3"], SpO2 [text size="3"]% [select name="SaO2" value="RA|Nasal Cannula|Facial Mask|"], [select name="Pain" value="0/No SX |1/10|2/10|3/10|4/10|5/10|6/10|7/10|8/10|9/10|10/10|"]pain.
[select name="POSS" value="Sleeping, easy to arouse|Awake and alert|Slightly drowsy, easily aroused|Frequently drowsy, arousable, drifts off to sleep during conversation|Somnolent, minimal or no response to verbal and physical stimulation "] oriented x [select name="x" value="4|3|2|1|0"]. Resident [checkbox value="is cooperative|interacts/communicates with staff|participates in plan of care|demonstrates appropriate safe behavior and follows safety instructions|"]. Resident is [checkbox value="agitated|anxious|angry|appropriate for situation|aggressive physically to others|aggressive physically to self|aggressive verbally to others|calm|cooperative|has delusions|flat affect|irritable|labile|pleasant|sad|non-compliant|restless"]. Respiratory pattern: [checkbox value="regular|irregular|symmetric|shallow|deep|labored|unlabored|dyspnea at rest|dyspnea at lying flat|dyspnea with exertion"]. Breath sounds [checkbox value="Clear|Diminished in ___|Rales|Expiratory wheezes|Absent|Crackles in ____|Inspiratory wheezes|Even|Stridor"]. [select value="Denies|C/o|"] [checkbox value="SOB|coughing|congestion"]. Respiratory interventions [checkbox value="cough and deep breathe|incentive spirometry|oral suction|supplemental O2 at __ lpm via __"]. Cardiac [checkbox value="S1,S2 no murmur or rub|RRR|no chest pain|no peripheral edema|no cyanosis|no JVD|no lightheaded|no syncope|capillary refill less than or equal to 2 seconds|pulses palpable|chest pain|edema|cyanosis|JVD|syncope"]. [checkbox value="On"] [text memo="anticoag" size="12"] [checkbox value="for DVT prophylaxis|for stroke prophylaxis|for A. Fib"]. [checkbox value="Next PT/INR"] [date]. [checkbox value="No A/R noted.|No bleeding, bruising,hematuria, hematochezia, nose bleeds, or bleeding gums.|Noted"][text memo="A/R?" size="12"]
[checkbox value="On "][select value="IV ABT|PO ABT"] [text memo="indication" size="12"]. [select value="PIV|PICC|Midline|VasCath|"] [text memo="loc" size="12"]. [checkbox value="No redness|No swelling|No leaking|No pain/discomfort|No infiltration or inflammation on vascular access site.|"]. [checkbox value="No A/R noted.|No nausea/vomiting/diarrhea."] Skin [checkbox name="skin" value="warm, dry and intact|color appropriate and even|rises easily and returns to place immediately|free of lesions, wounds, bruises, burns, abrasions, avulsions, rashes|free of infiltration and inflammation at the vascular access sites"] [checkbox value="Pale|Dusky|Ashen|Flushed|Clammy|Cool|Warm|Dry|Moist|"]. Gastrointestinal. On [text memo="diet" size="10"] with meal consumption of [select value="0-25%|26-50%|51-75%|76-100%|<50%|>50%"] [checkbox value="abdomen soft and non-tender,non-distended|bowel sounds present and normoactive in all four quadrants|elimination with resident's usual pattern|no palpable masses|absence of nausea, vomiting, constipation or diarrhea|absence of rectal bleeding|on tube feeding "]. Date of last BM [date]. Genitourinary [checkbox value="urine clear and pale yellow, no foul smell|continent with no bladder distention|foley catheter for__|nephrostomy tube|suprapubic catheter|"]. [select value="Denies|c/o"] [checkbox value="frequency|urgency|dysuria|hematuria"].
[select value="On PT/OT/ST|On PT/OT|On PT|"] [checkbox name="therapy" value="on scheduled days|, no documented therapy within 24 hours"]. [checkbox value="call light within reach|kept clean and comfortable|continue to maintain safety precautions|maintain fall precautions|continue safety monitoring|continue to turn every one hour|continue to maintain contact isolation precautions|continue to encourage to take scheduled medications|"]
Resident admitted to facility with dx:
Vital Signs: T F, HR bpm, , RR , BP /, SpO2 % , pain.
oriented x . Resident . Resident is . Respiratory pattern: . Breath sounds . . Respiratory interventions . Cardiac . anticoag . . A/R?
indication. loc. . Skin . Gastrointestinal. On diet with meal consumption of . Date of last BM . Genitourinary . .
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