Clinical Notes: Patient’s Name: Mrs.

Kristal
DOB: 10/11/1990 Room#: 111

Date/Time Discipline Focus DAR: Data, Action, Response

11/24/2023
D- Mrs. Kristal reported feeling slightly lightheaded and
fatigued during the morning. She also expressed a desire
1530H SPSW VS, to engage in some light mobility activities to alleviate
Mobility stiffness. Visual examination showed Mrs. Kristal in a
Trasnferring, seated position in her room. Vital Signs were recorded
Safety and BP: 120/80 mmHg, HR 78 bpm., RR 16, Temp: 98.6°F,
Comfort SpO2 98%. Mrs. Kristal exhibited cautious movements
and required assistance in transferring from bed to chair.
She displayed slight unsteadiness during the transfer.
AMarqueses SPSW

A
 Acknowledged Mrs. Kristal's subjective feelings
and ensured she was comfortable in her seated
position. Informed her of the plan to check vital
signs and engage in light mobility activities.
 Used appropriate equipment to measure vital
signs.
 Ensured the environment was calm and suitable
for accurate readings.
 Communicated with Mrs. Kristal throughout the
process to address any discomfort or concerns.
 Assisted Mrs. Kristal in transitioning from a
seated to a standing position.
 Encouraged gentle movements to improve
circulation and reduce stiffness.
 Monitored for signs of dizziness or fatigue during
the activity. A.Marqueses SPSW

R- Mrs. Kristal reported feeling more alert and less

fatigued after the vital signs check and light mobility
activities. She expressed satisfaction with the assistance
provided. Documented the vital signs readings and
mobility activities in Mrs. Kristal's record. Ensured Mrs.
Kristal was comfortable and provided any additional
support needed for her continued well-
being.A.Marqueses SPSW