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|  | BACKGROUND |  |\n| --- | --- | --- | --- |\n| Admit Date:   From:   Reason:   Hospital Course: | Tests Done | PMH: | Psychosocial:\u003Cbr>Decision Maker: |\n\nASSESSMENT  \nRECOMMENDATION / PT NEEDS TO-DO LIST  \n\n| Temperature\u003Cbr>NOC T-Max   Day T-Max   |  | Neuro: 4 3 2 1 ❑ EVD\u003Cbr>RASS   CAM + -\u003Cbr>GCS   |  | Cardiac\u003Cbr>EF:   Echo Date:  \u003Cbr>Rhythm:   | Hemodynamics ❑ A-Line\u003Cbr>❑ CVP Monitor\u003Cbr>❑ Swann |\n| --- | --- | --- | --- | --- | --- |\n| Pain |  |  |  |  |  |\n| Respiratory ❑ Clear\u003Cbr>❑ ET\u003Cbr>❑ Trach\u003Cbr>❑ Ch T\u003Cbr>❑ IS\u003Cbr>P/F Ratio:   |  | Vent Settings\u003Cbr>MODE   PS  Vt   | ❑ RT\u003Cbr>❑ ARDSFiO2   PEEP   RATE   | GI\u003Cbr>❑ NG ❑ OG ❑ PEG ❑ LWS  \u003Cbr>C-Diff: - + Last BM:  \u003Cbr>Diet | GU\u003Cbr>❑ Foley ❑ BSC ❑ BRP ❑ Anuric ❑ Dialysis\u003Cbr>NOCS DAYS\u003Cbr>In   Out  In   Out  \u003Cbr>In   Out   In   Out  \u003Cbr>In   Out   In   Out  \u003Cbr>Fluid Balance |\n| Muskuloskeletal |  | Skin |  | Drains | IV Sites |\n|  |  | ❑ Clear ❑ Dsng:   |  |  | ❑ PIV: |\n| ❑ SCDs\u003Cbr>❑ Boots\u003Cbr>❑ Sling | ❑ TEDs\u003Cbr>❑ Special Bed\u003Cbr>❑ Ambulating | ❑ Wounds:   |  |  | ❑ Central:\u003Cbr>❑ PICC:\u003Cbr>❑ Other: |\n|  |  | DVT & Stress Ulcer Prophylaxis:\u003Cbr>❑ Heparin ❑ Lovenox ❑ SCDs\u003Cbr>❑ Pepcid ❑ Protonix |  | Immune System\u003Cbr>Flu: ❑ Needs ❑ Received\u003Cbr>PNA: ❑ Needs ❑ Received\u003Cbr>MRSA: ❑ Admit ❑ > 7 Days in ICU |  |\n| Gtts |  | Sepsis: ❑ Infection ❑ Simple ❑ Severe Lab Draws ❑ K |  |  | Parameters |\n| 1)   @   2)   @   3)   @   4)   @   5)   @  \u003Cbr>6)   @   |  | Lactate:   CVP:   ScVO2:   ❑ Mg\u003Cbr>❑ Ph\u003Cbr>❑ Abx:   Given @ :  ❑ Ca\u003Cbr>❑ Abx:   Given @:  \u003Cbr>❑ Abx:   Given @:  \u003Cbr>❑ Abx:   Given @:  Accu-Check: |  |  |  |\n|  |  |  |  |  | PRNs Given |\n| 7)   @   |  | Cultures: ❑ Blood x2 ❑ Urine ❑ Sputum |  |  |  |\n\nNa:   K:   Mg:   Ca:   Ph:   Cr:   BUN:   WBC:   Hgb:   PLT:   PT:   INR:    \nLactate:   HCO3:   Other:  \nMISC","cbCaiflk9Rhtt5R3","https://ap.wps.com/l/cbCaiflk9Rhtt5R3","pdf",46736,"English","# Assessment\n## Safety and Isolation\n## Background and Intake\n## Neuro, Cardiac, Hemodynamics\n## Respiratory and Vent Settings\n## GI/GU, Skin, Drains\n## Prophylaxis and Immune System\n## Gtts, Sepsis, Labs and Cultures","[{\"question\":\"What patient information fields does the document capture at intake?\",\"answer\":\"It includes room number, diagnosis code, allergies, admit date, reason, hospital course, tests done, past medical history, and psychosocial notes with a decision maker field.\"},{\"question\":\"How does the document organize clinical assessment domains?\",\"answer\":\"It provides checklists for safety status and isolation type, then structured sections for neurologic status, cardiac and hemodynamics, respiratory/vent settings, GI/GU, skin and drains, and musculoskeletal mobility.\"},{\"question\":\"Which monitoring and lab-related items are included for ongoing management?\",\"answer\":\"The form includes infusion/“gtts” entries, sepsis status, parameters like lactate and CVP/SvO2, lab draw slots, culture types, and fields for key lab values plus PRNs given.\"}]","Brain Yellow - Patient Assessment Record - Clinical Notes Checklist | PDF",1789263745]