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It U Physician Assessment Sheet
It U Physician Assessment Sheet
It U Physician Assessment Sheet
MRN: …………………………………………………………….…
Sex: …………………………D.O.B.: ……………………………
Condition: Diagnosis/Impression:
ASSESSMENT SECTION
GCS: /15 E( ) V( ) M( ) Pupils: R L
Mental State:
Motor Power: UL ( / 5) LL ( / 5)
NEURO
Analgesia / Sedation:
Ventilation
RESPIRATORY
Peak TV
SpO2 FiO2 MODE PEEP
AP RR
/
ABG Date & Time
Oxygenation Ventilation Acid Base Examination CXR
PaO2/ Pa ET
PaO2
FiO2 CO2 CO2
pH HCO3 BE Ultrasound:
Secretions:
Last Vital Signs Perfusion Fingers/Toes:
HR / BP / CVP /
CRT Heart Sounds
Rhythm MAP JVP Oedema:
CARDIAC
Lactate: ScvO2:
Cardiac Output Monitoring
SV / SVR / Cardiac / vasoactive medication:
CO / CI FTC Impression / Echo
SVV SVRI
NG Fluid Balance
Input Output
Feed: NBM / PO / NG / TPN
FLUIDS / RENAL /
Crystalloid: Urine: / /
Glucose:
GI TRACT
Diuretics
Sounds: Colloid: Drains:
GAST RES:
Blood: Other:
Bowels Opened: Ultrasound:
Urinary Catheter:
Fluid Balance Yesterday
Urine Dip:
AST Alk P
Na+ K+ Mg2+ Ca2+ PO42- Cl- Urea Creat Alb Bili Gluc
ALT GGT
BIOCHEM / HAEM / MICRO
/ /
PT WBC Lymph
Hb Plt aPTT Fibrino. CRP T Max ºC
INR Neut Eosin
/ / /
Comorbidities:
PROBLEMS
ACTIVE
PaO2
MANAGEMENT PLAN
PaCO2
MAP
pH
Urine
Fluid Bal
Temp
Glucose
Hb
K+ Mg2+
Na+ Ca2+