Patient Assessment Form Patient Details Patient Name* Mobile No* Weight (Kg)* Gender MaleFemaleOther Patient's Email ID(to receive this Form in PDF): Hospital Details Hospital Name Hospital Location Bed no/Details Relative Name Relative no Consultant Doctor Current Location of The Patient HOMEWARDICU Chief Complaint Diagnosis Co-Morbidities DiabetesHypertensionCADThyroidOthers Bed Sore YesNo If Yes, Degree 01234 Fall Risk HighModerateLow Bed Ridden YesNo Inotropic Support in last 48 hrs YesNo Dialysis YesNo On Narcotic Drugs YesNo Febrile YesNo Restraints Required YesNo Lines Present ET Tube YesNo RT YesNo PEG YesNo Tracheostomy YesNo Foley's Catheter YesNo Central line YesNo Peripheral YesNo Drains YesNo ICD Tube(Chest Tube) YesNo Arterial Line YesNo Clinical Details Code Blue/Orange in last 72 hrs YesNo Intracranial Pressure Monitoring YesNo Bradycardia/Tachycardia YesNo Monitoring YesNo Hypertension/ Hypotension YesNo SpO2 < 90% Despite Supplementation YesNo Severe Oliguria/Anuria YesNo Ambulance Requirement YesNo Current Vitals Temperature Pulse BP RR SPO2 RBS Pain Score 012345678910 0 : No Pain 1-3 : Mild 4-6 : Moderate to Severe 7-9 : Very Severe 10 : Worst Pain Possible Delirium YesNo Respiratory Device VentilatorBipapNot Required Mode PCVCACSIMVCPAPNot Required O2 Support ABG Test pH PaCO2 PaO2 Hco3 Lactate SaO2 LAB Values Hb TLC Platelet ESR Blood Urea Creatinine Protein Albumin Ammonia Sodium Potassium Chloride GCS Kindly use the reference image given below Eye Opening Response 4321 Verbal Response 54321 Motor Response 654321 Name of the Assessor Name of the Doctor
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