Client Name:

Room #:
Code Status:
Diagnosis:
Co-Morbidities:
Oriented to: Person Place Time
Communication:
Pain:
PQRSTU: Provocation, Quality/Quantity, Region/Radiation, Severity Scale, Timing
Pupils:
O2 Sats:
Oxygen:
Hand Strength/Direction: RA
Foot Strength/Direction: RL
Difficulties Breathing Y/N:
RR:
Effort:
Rhythm:
Breath Sounds:

LA
LL

Chest Pain: Y/N

Apical Pulse:
B/P + Position:
Bowel Sounds:
Bowel Habits:
Skin:
Skin Turgor:
Peripheral Pulses:
Edema (Pitting/Non-Pitting):

Top Priorities:
1.
2.
3.

Medications:

Time Plan:
0800
0830
0900
0930
1000
1030
1100
1130
1200
1230
1300
1330

1400