UT-HARRIS COUNTY PSYCHIATRIC CENTER NURSING FLOW SHEET/PROGRESS NOTE(S) Day Shift 7 AM- 3 PM WIS ASSESSMENT Sulcide Homicidal DDeies Denied Citeaton CB Urges OPten CD Thveas OThest ——_Dhideaton D Safely Contract Fall Risk C1 None ‘Du nsioady gait Gcontuses OD Sedeted Diziness Recent fa Ciassistve device Requires assistance C Prost Comments, Elopemont denied Date Theat 11 Visual imaiement incontinence PSYCHOMOTOR: Ci Appropiae ChPoorposture Calan DRestessness Retardation Othe (sei, Comment. TTY (Ciatensng stuctired activities sat aos (Assistance provided wit ADL's Symptoms intrere win patents aby to atend ADL orgroup Comments oor Cale, Responsive Comments MOOD: CiAppoptat 0 Staton CElaled —GLabie C1 Dysphorc, Doth (speciy_ Commens, (DDecreased conscious (Othe (spect ‘euhymic PRYSIGAL ASSESSMENT: Check wiih norralmis (CNewriog: Stal and facial form, ea, nose tats symmetical, eyes equa, round (arovescul Heat rate rythm and peripheral Circulation tall edtenites, Nalbeds pk ih brisk cary ref [Respiration Breathing is prosentandefotess with roguat ae, hy and symmeticathoaceexcuson (Gastaitestinat Non dstended, regular and recent B's, ‘a and consistency. CGUIRenal Bader, on-distended. Vodts without pain, burning or cat. Unie reported as clear yellow to amber, (Musculskeleta Abe to move aetrerites with ul range ofmoton, Abseno® oil swelirg tendemess, © pan. No muscle woskness oss of sensaton. Seay at [Btegumentay: Warm and dy to touch with good turgor, éasity and color. No buses, lacerations o abrasions, [DOther spect). Comment (if abnoiiliy presen "THOUGHT PROCESS: DReeiant Goa directed Disoerizes DLoose [Other (Speci), Comments, concrete Tangenal CCieumsiantat MEDICATION: OCompiant Comment. TiNone Nan compat ‘ORIENTATION: CiPerson DPhace Comments, Dstuan Tine "APPEARANCE: CiWel groomed Neat DAppropiae for imate ‘Other (speci, Comments, Doisheveed CP hygiene Bcleen THOUGHT CONTENT: Cl Appropriate Stuaton DHalucnations Delusions Cr factie (i Petsecutry CAvitory T1Grandose EVisual 1 Ofacory (D Oe (Speci Comme SPEECH: C1Nermalatovolume Pressured Cikestant Othe (spec) Comments, DLoud Dshured OMue FAN: CCINo constants of pain CiRates pain sea 105, Comments, "AFFECT. CiApproprate lo Siuston (Depressed OBighi Hohe, Commer Clncongrent CoBunied Ch Anicus Fb PROGRES S NOTES (Handwrite notes at the appropriate margin, Note must begin with DATE and TIME.) “DIR” FormaUMTP # Heading Mp/DO- Nurse Other HCPC-80601:N (Rev. 06/03)UT-HARRIS COUNTY PSYCHIATRIC CENTER NURSING FLOW SHEET/PROGRESS NOTE(S) RISK ASSESSMENT” Suicide Denies ideation Pian O Theat Evening Shift 3 PM- 11 PM Homicidal Beried DUrges Threats Beaton Elopement copay rfl PHYSICAL ASSESSMENT. Check Twinn novmal iis Neurologic: Stull and facial fom, ears, nose thats symmetial, eyes equa round, [cardiovascular Hear rte rhythm and periher Ccuaion to all extemiies. Nalbeds pink wih brisk {Safety Contract Fell Risk C1 None ‘nsteady gat CiContused CO Sedetes Recent al Requires assistance Comments, (Visual impairment incontinence CDicziness CiAssistve devioe Prosthesis PSYCHOMOTOR: LiAgpropale Poor gesture C1 Catatoric CDRestessness __C1Retardaton Cotes (speci Comment. RTM. latendng structured actives Sat aDU's CD Assislaroe provided with ADL's {Symgtoms irtererewith patients ably to atlend to ADL's orgtoup Comments ve Aer Decreased conscious GResponsive Other (spec), Comments WOOD: CTAppOpae To Suston Clad CiLable Cl Oysphorc ‘Boner ope Comers RN Signature Deuthymic [DRespation: Breathing is resent and forts with reguler rate, thm and syrmetical oraic excursion [acastointesina: Non distended regu and recont BM, ‘ola and consistency, [TIGUIRenal. Bladder, nondisterded. Voss witout pan, turing or cul. Urine repaid as clear yin to amber [DNuscvostleta: Able to move al exteites wi ful range of maton, Absence of joint sweling, tenderness, or pin. No muse weaknass or loss of sensation Steady ai [Binlegumentcy: Warm and dy o touch wth good turgor, lastiy and color. No bruises, laceration or abrasions. ‘Othe (speci) ‘Comment if anarmally presen) THOUGHT PROCESS CDReevent Goal directed [DDsorganized Loose (Other (Sect Comments, Dconcrete CTongential CO creunstantat TEDIGATION: Compan. Comments, TiNone CINon-complant ORIENTATION: Person Place Comments, Dsivaion OTine APPEARANCE: Wel groomed Neat 1 Approptat for eimate 1B Othe (speci) Comments, DDishoveed D Poor hygiene Ociean THOUGHT CONTENT: Co Aopoprteosanbon CHalucinaions C1 Deisions TD Tacbie OPerecutoy CO Autry Ciansse Vial 0 Ofacory 10 othe (Specty_ Comments SPEECH Normal athalume (Pressures Hest, Other spec Comments, Loud OStured OMe PAN: CIN complains of pain ‘ChRates pain scale 1105, Comments, AFFECT: Ui Feproprate to Giuaton (Depressed Dietght Cincongizent Dome, Comments CoBlunied CO arsous oF PROGRESS NOTES (Handwrite notes at the appropriate margin. Note must begin with DATE and TIME.) “DIR” Format/MTP # Heading HOPCHOGOLN (Rev, 06/08)