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2022-10-06T16:09:32+00:00
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Client
ID
Date
Name of nurse
I verify that the nurse worked and provided direct care to the client for the hours shown and date indicated. I understand that if I intentionally sign for hours not actually worked, I could lose benefits, I agree not to pay or advance any money to employees, and I will not deduct any such payment from invoices.
NEUROLOGICAL
LOC
Alert
Oriented
Impaired
Responsive
Unresponsive
Active
Irritable
Lethargic
Restless
Sedated
Seizures
Active
None
HX
TONE
Hypo
Hypertonic
Flaccid
Normal
Spastic
FONTANEL
Flat
Sunken
Bulging
Closed
SHUNT
Present
Absent
EYES / VISION
WNL
Impaired
Blind
Drainage
yes
no
PUPILS
Equal
Unequal
Reactive
Non-reactive
SPEECH
Normal
Delayed
Non-verbal
HEARING / EARS
WNL
Deaf
Drainage
Impaired
Hearing aides Left
Hearing aides Right
MOBILITY
Approp
Delayed
Immobile
Para
Hemi
Quadra-plegia
Crawls
Walks
Rolls
Full ROM
Scoliosis
Contractures Upper Ext L/R
Contractures Lower Ext L/R
BEHAVIOR *=See narrative
Co-opperative
Resistant
Oppositional
Combative
Defiant
Verbally abusive
RESPIRATORY
NOSE / SINUSES
WNL
Congestion
Drainage
RETRACTIONS
SUBCOSTAL
INTERCOSTAL
SUPRASTERNAL
SUBSTERNAL
Cough
Productive
Non-productive
Chest Expansion
Symmetric
Asymmetric
ARTI FICIAL AIRWAY
Patent
Secure
Brand Shiley
Bivona
Other
Trach Size
Pedi
Neo
Other
Uncuffed
Cuffed
EFFORT
Labored
Unlabored
Nasal
Flaring
Grunting
Trache Size
Trache type
Bivona
Shiley
LEFT BREATH SOUNDS
Clear
Coarse
CRrackles
Wheezes
Diminished
Upper
Lower
RIGHT BREATH SOUNDS
Clear
Coarse
CRrackles
Wheezes
Diminished
Upper
Lower
CARDIOVASCULAR
HEART SOUNDS
Ryhthm
Regualr
Irregular
PERIPHERAL PULSES
Palpable X4 extremities
REFILL
B < 3 secs
SL 3-5 secs
NAILBEDS
Pink
Pale
Dusky
SKIN TURGOR / HYDRATION
Normal
Decreased
Edema present
yes
no
MUCOSA
Moist
Pink
Pale
Dry
GASTROINTESTINAL
ORAL / DENTAL
Gums
Normal
Swollen
Red
Cleft
Palate
Lip
Teeth
Full set
Teething
THROAT/SWALLOWING
Normal
Impaired
Bowel Sounds Absent
yes
no
ABDOMEN
Soft
Tense
Firm
Flat
Rounded
Distended
Nausea
Vomiting
BOWEL SOUNDS
Present
active X 4 quads
Hypo active
Hyper active
Normal
BOWEL PATTERN
Reguar
Irreguar
Continent
Incontinent
Bowel Program
Other
FEEDING STATUS
NPO
PO
Enteral feeding
PO Appetite
Good
Fair
Poor
Stoma
pink
healthy with bag intact
FEEDING TUBE
BRAND
NG OG Size
NG OG Size FR (cm)
G-Tube Size
G-Tube Size FR (cm)
JT GJ Tube Size
JT GJ Tube Size FR (cm)
GENITOURINARY
GENITOURINARY
Distension
Retention
Neurogenic
Continent
Incontinent
Catheter
Indwelling
IO in
IO out
Color
AMBER
BLOODY
BROWN
GREEN
STRAW
WHITE
YELLOW
CLEAR
CLOUDY
Catheter type
size (fr)
Menses
SAFETY
Emergency Plan / Info Reviewed
Reviewed
Yes
No
Side rails X
Up
Down
Not in use
PRECAUTIONS
Universal
Oxygen
Respiratory
Aspiration
Reflux
Seizure
Infant
Child
Fall
Sharps
Infection
SKIN
Type
Warm
Cool
Clammy
Type
Dry
Moist
Diaphoretic
Type
Rashes
Itching
Breakdown
Type
Icisions
Wounds
Type
CVL
PAC
PICC
PIV
STOOL
SOFT
FORMED
SEMI-LIQUID
LIQUID
SEEDY
Finishing
Client/Family Education Topic
Time spent
Caregiver(s) Instructed
Caregiver Response/Understanding
Parent/Caregiver/Legal Guardian has previously demostrated knowledge and the appropriate skills to care their child as ordered by the physician. No teaching performed
Report received from
All meds, care & Tx given
Yes
No
Narrative Note
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