Assessment / REport Data Sheet

I have been wanting to consolidate a Pt. Data sheet for some time. YOu know, the kind that can split in half a page, have both sides used, and be copied off of the computer onto card stock paper?

I would love some feedback on what to add or take away for a General Floor Nurse m/s Adult environment Data Sheet.

Assessment side:

This is nice! A good reminder to be a really thorough assessor!

In the pain section, maybe the pain scale and a location area rather than just something to circle (other than the acute vs chronic options)?

How about a learning needs, and/or education performed area?

Report side:

Area for I&O's, last shift and this shift?

Area for "ask about", to scribble "reminders to self" on questions for doc, or something the patient asks you to do for them or find out for them.

Great suggestions, thank you. Duh! REgarding the I & O's.

I also use my report sheet; it is generic and has the old report info on it but it is not enough room for all the assessment info. that I like to include in my report and to jog my memory of what to note via the facility paperwork.

I do have a built in habit of circling what I am unclear about or I make an underscore line to later add info. I also have learned, on busy hectic days, to show on my sheet that I have done assessment and charted (sort of a quickey reminder often to chart the assessment on the facility flow sheet.

I work Agency and find that I have to have my own strong organized (consistent) paperwork so I can adapt to the facilities paperwork!

Thanks for the add on suggestions!

Here is the New Sheet. On this one, I circle Concerns or highlight and underscore those areas not done or those that need revision.

night

Assessment Flow Sheet.doc

Pt Info on other side of Assessment Sheet.doc