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Assessment Form

University Hospital

This is an example online assessment and documentation form. This form is meant to simulate the completion of ehealth chart documentation using a proprietary system. Complete the form as required to simulate entering data into a ehealth chart. Note: An ehealth assessment form would include all body systems pertinent to a head-to-toe assessment (Vitals, CNS, RESP, CVS, GI, GU, Integument, Mobility, Psychosocial, Long Notes). Due to the limitations of this form, only Vitals, CNS, RESP, and CVS data entry, as well as nursing long hand charting, are simulated.

Admission Date: Jan 19, 20XX

Transfer by: Ambulance

Allergies: None

Advanced Care Directive: On File, SMOST Category M2

Assessment time
AM
PM
Other, specify

Clara Plante

15/August/19XX

Female

HSN: 825545737

Is an update being made to the Advanced Care Directive at the time of this assessment?
No
Yes (make referral to physician)

Vital Signs:

Thermometer:
Oral
Axial
Rectal
Tympanic Otic
Tympanic Dermal

CNS:

Oriented:
LOC
Pain

RESP:

Cough
Not present
Present with secretions
Present without secretions
Lung Sounds
Air entry equal bilateral and in lung fields
Air entry not equal, or abnormal sounds present (describe)

CVS:

Pulses

Left Radial
0
+1
+2
+3
Right Radial
0
+1
+2
+3
Left Dorsalis
0
+1
+2
+3
Right Dorsalis
0
+1
+2
+3

Capillary Refill

Left Hand
0sec
1 sec
2 sec
3 sec
4 + sec
Right Hand
0sec
1 sec
2 sec
3 sec
4 + sec
Left Foot
0sec
1 sec
2 sec
3 sec
4 + sec
Right Foot
0sec
1 sec
2 sec
3 sec
4 + sec

Edema

Left Upper Limb
0
+1
+2
+3
+4
Right Upper Limb
0
+1
+2
+3
+4
Left Lower Limb
0
+1
+2
+3
+4
Right Lower Limb
0
+1
+2
+3
+4

Interprofessional Notes (long hand charting)


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