PRE-ARRIVAL:
SUBJECTIVE:
-History of Present Illness-
-Patient Histories-
Medications, allergies, and medical history documented elsewhere.
OBJECTIVE:
Primary and secondary assessment performed as documented elsewhere.
-Lab Values-
ASSESSMENT:
PLAN:
Treatments as documented elsewhere.
DELTA:
-Hand Off-
Mental Status:
Patient alert; Oriented to person, place, time and event. Behavior appropriate to situation.
Skin:
Skin pink, warm, dry and intact with strong regular distal pulses. No areas of localized discoloration or temperature change. No rash, no bruising.
HEENT:
Airway patent with good air movement. Patient speaks in full sentences. Trachea midline. Pupils equal and reactive to light.
Chest:
Lung sounds clear and equal bilaterally with adequate and even chest expansion. Breathing pattern regular. No accessory muscle use or retractions noted. Patient denies chest pain, shortness of breath, or dyspnea.
Abdomen:
Abdomen soft, non-tender, non-distended in all four quadrants. Patient denies nausea, vomiting, diarrhea and constipation.
Extremities:
Extremity strength appropriate and equal. Range of motion intact. Distal pulses present. Extremities warm.
Neuro:
Face and strength symmetrical. Speech and gait normal. No numbness or tingling. No memory issues.