Name :

MRN : D.O.B :
GENDER: MALE FEMALE

VITAL SIGNS BED NO : AGE :

INSTRUSTIONS :
1. Use ' Key ' accordingly - BP - TEMP - PULSE - RESP X - PAIN
2. Use Red Pen for Pulse (Black Pen) (Red Pen) (Blue Pen) (Black Pen)
3. Use Blue Pen for Respiration

DATE
TIME
PULSE BP TEMP PAIN
RESP °C SCORE
250 10

240 9

180 230 8

170 220 7

160 210 6

150 200 5

140 190 4

130 180 3

120 170 2

110 160 42 1

100 150 41

90 140 40

80 130 39

70 120 38

60 110 37

50 100 36

40 90 35

30 80 34

20 70

10 60

SPO ₂
SIGN
STAFF NO
Rate the Severity of Pain
0 1 2 3 4 5 6 7 8 9 10
No Pain Mild Pain Moderate Pain Severe Pain Worst Pain

KPJAPSH/NSG - 02/ISSUE.04/MARCH 12