Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Washed/shower?
*
Yes
No
Uses walking aid?
*
Yes - Zimmer frame assistance of 2
Yes - Molift assistance of 2
No - Hoist transfer
No - Nursed in bed
Skin intact?
*
Yes but vulnerable - Redness
Yes but vulnerable - Rashes
No - Moisture damage
No - Blister
No - Popped blister
No - Grade 1 pressure sore
No - Grade 2 pressure sore
No - Grade 3 pressure sore
Any wounds on the body?
*
Yes - Surgical wound (specify site in your actual notes)
Yes - Wound on leg
Yes - Arm
Yes - Abdomen
No
Any attached/invasive devices?
*
Yes - Cannula
Yes - Catheter
Yes - Cardiac monitor
Yes - Drains
No
Eating and Drinking
*
Yes but - Needs help
Yes but - Not eating enough
No - Nil by mouth pending surgery
No - Swallowing difficulties
No - Unconscious
No - Having NG feed
No - Refused
Continent?
*
Yes but - Constipated
Yes but - Has a stoma bag in situ
No - Incontinent of urine
No - Incontinent of bowels
No - Incontinent of both bowels and urine
attached/invasive infections? the
NEWS and general well-being OK?
*
Yes but - Undergoing normal care
Yes but - Stable NEWS but on IV medication
No - NEWS is not stable
No - Patient is deteriorating
No - Patient is acutely unwell
Having medication
*
Yes - Only on tablets
Yes - On both tablets and IVs
Yes - Only on IVs
No - Refuses medication
Reviewed by the doctor?
*
Yes
No
No need
Care plan updated and followed?
*
Yes
No
No clear care plan created
Have any infections?
*
Yes
No
Awaiting results to determine
NOK updated?
*
Yes
No
No NOK Documented
Any plans for discharge
*
To go home
To go for rehab
Nursing home
No
Unsure
Any extra details?
*
Submit