< Back
Daily Skills Report
Transcriptions
Condition Monitoring
List Diagnosis or Condition(s) being monitored *
Vital Signs
Blood Pressure (mmHg) *
Blood Pressure Date *
Position *
Temperature (°F) *
Temperature Date *
Route *
Pulse (bpm) *
Pulse Date *
Pulse Type *
Regular
Irregular
Respiration (breaths/min) *
Respiration Date *
O2 sats (%) *
O2 sats Date *
Method *
Trach
Nasal
Mask
Pain Assessment
Pain *
Yes
No
Pain Level (0-10)
Pain Level Date
Blood Glucose Monitoring
Blood Glucose Monitoring *
Yes
No
Blood Glucose (mg/dL)
Blood Glucose Date
Were any Teachings/Education provided *
Yes
No
Is blood glucose level at baseline or well controlled
Yes
No
Do the Vital Signs show fluctuations from baseline that require intervention(s) *
Yes
No
Describe Observations, Interventions and/or Resident Response to intervention and/or Notification(s) made *
Cognition, Mood, Behavior
Status *
Alert
Not Alert
Oriented *
Oriented x 1
Oriented x 2
Oriented x 3
Not Oriented
Active Symptoms or Treatments effecting Level of Consciousness, Cognition, Sleep, Mood, or Behavior *
Yes
No
Neurological
Motor response *
Within baseline
Not within baseline
Pupil response *
Within baseline
Not within baseline
Active Symptoms or Treatments effecting the Neurological system
Decreased level of consciousness
Seizure activity
Tremors
Paralysis
Numbness/tingling
Dizziness
Other neurological symptoms
No active neurological symptoms observed
Respiratory
Respiratory rate, rhythm, sound *
Within baseline
Not within baseline
Skilled Respiratory services
Respiratory Therapy
Active Symptoms effecting Respiratory system
Abnormal breath sounds
Cough
Dyspnea
Decreased O2 saturation
Labored breathing
Pain with breathing
Shortness of breath
Other respiratory symptoms
No active respiratory symptoms observed
Current treatments that require Respiratory system monitoring
Oxygen therapy
CPAP/BiPAP
Suctioning
Tracheostomy
Ventilator
Nebulizer treatment
Inhaler
Chest physiotherapy
HOB elevated due to shortness of breath lying flat
Describe Observations, Intervention(s), Residents Response to intervention and/or Notification(s) made *
Initializing form... Recording will be available soon.
0%
Save and Continue
Save Draft