Atal Bihari Vajpayee Institute of Medical Sciences and

Dr Ram Manohar Lohia Hospital

Baba Kharak Singh Marg, New Delhi-110001
NURSES DAILY ASSESSMENT FORM WITH NURSES NOTES

Patient's Name : ................................................................................................. Age/Sex......................... UHID : ..........................................

MRD No. : ..........................................................................Consultant.............................................................................................................

Date & Time of Receiving the Patient :...............................................................................................................................................................

VITAL ASSESSMENT

Temp (°F) Pulse/Minute Respiration / Minute Blood Pressure SpO2 Weight (Kg)
(if advised)

VULNERABILITY ASSESSMENT

Assessment
Vulnerable Category Needs & Action
(If "Yes" provide
Assistance in
Meeting needs as
listed)
 Elderly > 75 yrs Yes No  Eating
 Toileting
 Physically & Mentally Challenged Yes No  Mobilization
 Activities of Daily Living
 Infectious/Communicable Disease Yes No  Initiate Isolation/Reverse Barrier
 Immuno Compromised Yes Nursing (as applicable)
 Dietary Referral
Chronic / Intense Pain[ Pain Yes No  Refer to Physician
Score(0-3)]  Pain Medication
 Provide comfort
Cannot Perform ADL Yes No Provide assistance based on further
functional assessment
Terminally ill Yes No  Initiate End of Life Care
 Special Religious / Cultural Needs
Suspected Drug and / or AlcoholDependence Yes No Refer to Physician

Chemotherapy Yes No Provide supportive care

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 Atal Bihari Vajpayee Institute of Medical Sciences and
Dr Ram Manohar Lohia Hospital
Baba Kharak Singh Marg, New Delhi-110001
PRESSURE ULCER ASSESSMENT
Consider Patient as having risk of pressure ulcer in case any of the following if yes:

History of prior ulcer Yes No

Previous treatment/surgical Yes No
Pressure intervention for pressure ulcer
Ulcer Incontinent Yes No
Impaired sensory perception Yes No
Inability to changed position oneself Yes No
Presence of ulcer currently Yes No Document details :

Presently at risk pressure ulcer Yes No If yes initiate action Plan with Braden
Scale

FALL RISK ASSESSMENT (MODIFIED MORSE SCALE)

Variables Numeric Values Score

1. History of falling No 0

Yes 25 .......................

2. Secondary Diagnosis / Elimination Problem No 0

Yes 15 .......................

3. Ambulatory Aid
None / Bed Rest / Nurse Assist 0
Crutches / Cane / Walker 15
Furniture 30 .......................

4. CNS / CVS medication

No 0
Yes 20 .......................

5. Gait
Normal / Bed rest / Wheel chair 0
Weak 10
Impaired 20 .......................

6. Mental Status
Oriented to Own ability 0
Overestimated of forgets limitations 15 .......................
0 to 24 (low risk) 25 to 44 (medium risk) Above 45 (high risk) Total fall scale score

If Score is > 24, patient family is educated for all prevention: Yes ........................ No. …………...............

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 Atal Bihari Vajpayee Institute of Medical Sciences and
Dr Ram Manohar Lohia Hospital
Baba Kharak Singh Marg, New Delhi-110001

Signature &
Shift (Time) Nursing Notes
Emp Code

Page 3 of 4
 Atal Bihari Vajpayee Institute of Medical Sciences and
Dr Ram Manohar Lohia Hospital
Baba Kharak Singh Marg, New Delhi-110001

Signature &
Shift (Time) Nursing Notes
Emp Code

Page 4 of 4