Neurological mental status cranial nerves sensory

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Neurological (mental status, cranial nerves, sensory, motor, deep tendon reflexes, pupils): Musculoskeletal (ROM, dorsalis pedis and post-tibial pulses, muscle strength of upper and lower extremities): Genitourinary (burning with urination, frequency, color of urine): Urinary incontinence: Toileting plan: Pelvic (female: LMP): Rectal (bleeding, hemorrhoids): Integumentary (rashes, lesions, wounds, etc.): Specialty assessment (mental health exam, fetal heart rate, etc.): Abuse screen (physical, elderly, child, sexual, etc.): IV access (type/size, site, reason for IV access, type of fluid/rate, reason for type of IV fluid, assessment of IV site, last dressing change): 0830 100.8 99 20 95 93/54 154.94cm 69.6kg Back Pain Better with meds/ when pain meds are wearing off Sharp/ Stabbing No Radiation 8 Constant Pt head is normocephalic, no leasions or infestation, hair evenly disstrubed, Jandice Pattern regular, denies SOB, 96% on room air, all lobes are clear, no accessory muscles used Regular pulse rate, cap refill <3, all anatomical points heard, no JVD Round, BS Present *4 continence Bathroom as needed 3/17/21 Pt is alert and oriented *4, CNs Intact, DTR is intatct Pt has full ROM in both upper and lower extremities, 5/5 strength bilaterally, pulses 2+ bilaterally Blood in urine, decreased urine output, amber color continence Bathroom as needed N/A no issue noted Braden score 20, Skin intact except left IV N/A No abuse suspected 2 left forearm IVs, Ivs in tact 1330 100.8 104 20 96 104/64 154.94cm 69.6kg Back Pain Better with meds/ when pain meds are wearing off Sharp/ Stabbing No Radiation 4 Constant Pt head is normocephalic, no leasions or infestation, hair evenly disstrubed, Jandice Pattern regular, denies SOB, 96% on room air, all lobes are clear, no accessory muscles used Regular pulse rate, cap refill <3, all anatomical points heard, no JVD Round, BS Present *4 continence Bathroom as needed 3/17/21 Pt is alert and oriented *4, CNs Intact, DTR is intatct Pt has full ROM in both upper and lower extremities, 5/5 strength bilaterally, pulses 2+ bilaterally Blood in urine, decreased urine output, amber color continence Bathroom as needed N/A no issue noted Braden score 20, Skin intact except left IV N/A No abuse suspected 2 left forearm IVs, Ivs in tact
1-180405 ©2019 Chamberlain University LLC. All rights reserved. 0119pflcpeADA CLINICAL LEARNING – DIRECT PATIENT CARE DOCUMENTATION LEVEL 3 CLINICAL COURSES PAGE 4 OF 10 CHAMBERLAIN UNIVERSITY National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | 888.556.8226 | chamberlain.edu Please visit chamberlain.edu/locations for location specific address, phone and fax information. Labs Test Result/ Date Norm Reason out of norm/reason for drawing if normal or N/A if not drawn WBC RBC Hgb Hct Plt Chol Trig LDH PT APTT AST ALT Tdl* * Therapeutic drug level Test Result/ Date Norm Reason out of norm/reason for drawing if normal or N/A if not drawn Glu BUN Na K Cl Creat CO2 Ca Phos Mag T. Pro Alb Tdl* Telemetry Rhythm Strip: Attach your patient’s rhythm strip below and determine the following information: PRI: QRS: QT: Rate: Rhythm: N/A N/A N/A N/A N/A N/A 6.4 4.5-11.0 No health conditions that require a

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