Assessment & Plan Elements
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[checkbox name="Vitals" value="VS Stable|HTN |Tachy|Bradycardic|Elevated Temperature|Hypotensive|Low O2 Sat%|HTN CRISIS"][checkbox name="Appearance" value="poor hygiene|disheveled|inappropriate attire|well-groomed|appropriate attire"][checkbox name="Functioning" value="A&Ox4|confused|impaired judgment|impaired insight|memory impairment|abnormal movements|tremors|tearfulness|tangenital|able to make needs known"][checkbox name="Behavior" value="Cooperative|Calm|Pleasant|Uncooperative|Threatening|Aggressive|Agitated"][checkbox name="Mood/Affect" value="congruent|blunted/flat|labile|depressed/sad|anxious|irritable|angry|hostile|intense|hopeless/helpless|worthless|anhedonia|euthymic|euphoria"][checkbox name="Complaints/Concerns/Questions" value="pain|insomnia|hypersomnia|nightmares|fatigue|anxiety|depression|feeling unsafe|nausea|vomiting|diarrhea|chest pain|SOB|tremors|heartburn|constipation|body aches|cough|confusion|weight gain|weight loss|fear|safety issues|suicidal thoughts|homicidal thoughts|feeling ill|sore throat|headache|cramps|breast tenderness|abdominal pain|inc. irritability|hallucinations|paranoia|delusions|itching|rash|inc. cravings to use|stiff joints|palpitations|dizziness|bleeding "][var name="This RN asked client what their daily goal is, client stated,"][text name="Daily Goal"][checkbox name="Med Admin/Refusal/Etc" value="AM meds admin as ordered|PM meds admin as ordered|PRN med(s) admin as ordered|Client refused|No show for meds|At an outside meeting for scheduled med pass|Not in stock; awaiting the arrival from pharmacy|Not on property|No further questions, concerns, complaints at this time"][checkbox name="SI/HI/AVT Hall/Delusions/Safe" value="Denies SI/HI|SI|HI|Intent|Plan|Passive|Plan|A/V/T Hallucinations|Delusions|Safe|Unsafe|Fearful|Manic|Bizarre|Concerning|Guarded|Isolative|Contracted for Safety with this RN|CCA/Housing Notified|COC Notified|Medical Notified"]This RN will continue to monitor.
This RN asked client what their daily goal is, client stated, This RN will continue to monitor.

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