Doesn't yet see the picture
1 pts
Sees part of the picture
2 pts
Sees the basic picture
3 pts
Sees the big picture
4 pts
Anticipates the changing picture
5 pts
Total Score for this column.
(N/A)
Name DOB
Most recent labs pertinent to diagnosis
Past Medical History Family Medical History Social History
CC and/or Primary diagnosis Secondary diagnosis
Review of patient allergies
Lists vital signs obtained throughout shift
Update and Review of patient medications
Head to Toe Resident Data Assessment
ADL's, Hygiene, etc.
Fluid measurements in/out Food percentage intake Elimination measurements
Lists wounds and descriptions. Indicates if none found.
Enters Nursing Diagnosis Statement, Goals, Interventions, Rationale, Evaluation
Has entries no less than every 2 hours.