170/171 GERI CHARTING/SYSTEMS APPROACH

Student Name____________________________________ Date___________

PATIENT INFO:
Admitting dx and date________________________
PMH:______________________________________
Surgery and date_____________________________
Age____ Sex_____ Advanced Directives?
_________
Allergies:____________________ Isolation precautions?___________________________
ALL ENTRIES SHOULD BE TIMED AND SIGNED. THIS WILL BE GRADED AS A LEGAL
DOCUMENT
Document 2 assessments with follow through.

Use Kellys yellow card. Document interventions for any abnormal and patient response.
Proceed with appropriate assessments learned in 121/170/171 and documentation of the
same.

Abnormals - note by circling. Notify RN and instructor, recheck every 1-2 hours and
document

VITAL INFORMATION:
______________________________

Trend info?

Time: _____ T:
O2 or RA?

P:

R:

BP:

O2 SAT

_____L

Time: _____ T:
O2 or RA?

P:

R:

BP:

O2 SAT

_____L

BS AC & HS if DM
HS____________

7:30 __________
A1C__________

11:30__________ 4:30 __________

Ht:__________Wt: __________BMI:__________ Daily weights?_____Results:

__________________
Remember: ALL ENTRIES SHOULD BE TIMED AND SIGNED.
PAIN:_S
data_________________________________________________________________________
(COLDSPA)____________________________________________________________________________
_____________________________________________________________________________________
_
_____________________________________________________________________________________
NEUROLOGICAL/EENT/BEHAVIOR/MOOD (LOC/ORIENTATION - A&O, PERRLA, Smile
symmetrical, Speech clear, Tongue midline, Hand grasp/arm raise/MAE?)

S____________________________________________________________________________________
O ___________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
INTEGUMENTARY (WOUNDS/INCISIONS/ Braden Scale/ Signs of bleeding? /TURGOR)
S____________________________________________________________________________________

O ___________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Pg. 1 of 4
RESPIRATORY (Resp at rest and with activity (DOE?)
S____________________________________________________________________________________
O ___________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Date and ABG results?
__________________________________________________________________
CARDIAC (on tele?rhythm_____ ). Apical pulse with VS and describe. BNP and
date______Troponin levels?
Apical_____________Radial___________Pulse deficit?_________Telemetry/ leads/rhythm

S____________________________________________________________________________________
O ___________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
GASTROINTESTINAL
S___________________________________________________________________________________
_O
___________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
URINARY (ADLs addressed= toileting , ? HOURLY OUTPUT ADEQUATE? 24 hr. fluid
balance information, BUN, Cr, lytes)

S____________________________________________________________________________________
O___________________________________________________________________________________
_____________________________________________________________________________________
I & O (6 am until noon) Diuresing???
_________________________________________________________________________
Intake

Output

Oral

Void

IV total

Foley

Other

Other

total

total
Fluid
balance

PERIPHERAL VASCULAR/ CMS-

Document upper extremities prn. Angio PUNCTURE SITE?

Upper
extremities___________________________________________________________________________________________________

Lower extremities:
S____________________________________________________________________________________
C(5)_________________________________________________________________________________

M(3)________________________________________________________________________________
S (3)_________________________________________________________________________________
DVT px, TEDS/SCDs, meds?
________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Pg. 2 of 4
MOBILITY/MUSCULOSKELETAL (Activity order, activity level (ROM, gait) and
tolerance/intervention) ??PT/premedicate? ADLs addressed =ambulation, transfer

S____________________________________________________________________________________
O ___________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
SELF-CARE/HYGIENE ADLs addressed bathing, dressing, grooming. OT? IADLs?
Independent or describe type of bath given/assistance needed. Oral care, Foley care.

S___________________________________________________________________________________
_
O___________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
NUTRITION (Diet order/% Eaten, fluid intake, TEACHING?)
Diet order _________________________Amount eaten/drank
ADLs addressed feeding - Independent?

S____________________________________________________________________________________
O___________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
SAFETY ASSESSMENT&INTERVENTION
_____Patient ID wrist band. (colors?statewide= Purple- DNR, Red- Allergy, Yellow-Fall) How IDed?
______________________
_____Infection control handwashing in and out of room
____taught patient/caregivers to do the same
Fall risk/reasons?
_______________________________________________________________________________________
Intervention (including Assistive devices, Bed rails, Bed alarm, Restraints)
Bleeding precautions? _________________________Chemo precautions?
_________________________________________
Seizure precautions? __________________________Alcohol withdrawal protocol?
__________________________________

S___________________________________________________________________________________
O___________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

IV (SOLUTION- RATE- SITE/dates and time hung)/ Tube reconciliation(Preplan on

tube?)

S____________________________________________________________________________________
O ___________________________________________________________________________________
_____________________________________________________________________________________
IV medications? _________________ Date tubing
change____________________________________

Pg. 3 of 4
OTHER LABs/DIAGNOSTICS?
_____________________________________________________________________________________
_____________________________________________________________________________________
CBC/date
CHEMISTRY/date
1.3-2.1
Mg

A=Assessment D=NURSING
the day)

DIAGNOSIS (based on S and O data, patient goals for

_____________________________________________________________________________________
_____________________________________________________________________________________
ADDITIONAL NOTES from report/chart review(H&P)/other
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
PLAN - RATIONALE FOR ABNORMALS CIRCLED AND ACTION NEEDED (Call MD,
Give Tx or Med, Etc)
SBAR: Reported following to RN:________________________________________________________
Reported following to instructor:___________________________________________________

INTERVENTIONS addressed under appropriate system.

_____IC handwashing in and out of room.
_____Completion of skill
______________________________________________________________________________

Eval of support system, spiritual needs, living arrangements, discharge

plan
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Therapeutic communication technique used/patient

response_______________________________________________________________________
______________________________________________________________________________________________________

Patient education/self care: Attach one patient ed handout used on the

floor for needs of your client today. How did you use this (or how will you
use it next time?)
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Name___________________________________________Initials________________
Date___________
Pg. 4 of 4
1/2012

LB