Ridhi Sidhi Soft |

Chief Complaints

Duration

#	Chief Complaints	Duration	Date	Username	Action
{{$index + 1}}	{{x.Chif_com}}	{{x.DUra}}	{{x.CrDate}}	{{x.UserBy}}

Consultant Doctor Name

Doctor Note

Sno	Date	NOTE	Dr. Note	USER	Action
{{$index + 1}}	{{x.DateTS}}	{{x.DrNote}}	{{x.DoctorNm}}	{{x.UserBy}}

Note's

Sno	ID No	NOTE	Date	USER	Action
{{$index + 1}}	{{x.Sno}}	{{x.NUSnote}}	{{x.Datet}}	{{x.Unmae}}

Treatment History (Before Admission)

#	Date	Treatment History	UserName	Action
{{$index + 1}}	{{x.DataC}}	{{x.Treatment_History}}	{{x.UserNo}}

History of Presenting illnes

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#	Date	Treatment History	UserName	Action
{{$index + 1}}	{{x.DataC}}	{{x.History_Presenting}}	{{x.UserNo}}

Vaccination History

#	Date	Vaccination History	UserName	Action
{{$index + 1}}	{{x.DataC}}	{{x.Vaccination_History_Note}}	{{x.UserNo}}

Ongoing Treatment /Medications (Before Admission in ICU)

#	Date	Ongoing Treatment	UserName	Action
{{$index + 1}}	{{x.DataC}}	{{x.PHM_OngoingName}}	{{x.UserNo}}

Reievant Prior Investigation

#	Date	Ongoing Treatment	UserName	Action
{{$index + 1}}	{{x.DataC}}	{{x.PHM_ReievantName}}	{{x.UserNo}}

Main Issues at Admission

PLAN

#	Date	Main Issues at Admission	PLAN	UserName	Action
{{$index + 1}}	{{x.CrDate}}	{{x.ADminISuue}}	{{x.ADPlan}}	{{x.UserNo}}

CLINICAL NOTE

#	Date	CLINICAL NOTE	UserName	Action
{{$index + 1}}	{{x.CrDate}}	{{x.CLINICALNOTENM}}	{{x.CrUserBy}}

Name Of Test

Send Date

Tentative Reaport Date

Reaport

#	Date	Name Of Test	Send Date	Tentative Reaport Date	Reaport	User By	Action
{{$index + 1}}	{{x.CrDate}}	{{x.HMS_SPLTESTNM}}	{{x.HMS_SPLTESTSENDDATE}}	{{x.HMS_SPLTESTTANTREPORT}}	{{x.HMS_SPLTEST_REPORT}}	{{x.CrUserBy}}

Procedure Name

Site

Performed by

Remarks

#	Date	Procedure Name	Site	Performed by	Remarks	User By	Action
{{$index + 1}}	{{x.Crate}}	{{x.ProcedurepName}}	{{x.ProcedureSiteNm}}	{{x.ProcedureProformBy}}	{{x.ProcedureRemarks}}	{{x.UserBy}}

Temp

Pulse

W+

H+

RISK FACTOR
SENSORY PERCEPTION Ability to respond Meaningfully to Pressure related Diisconmfort	1. Completely Limited Unresponsive (Does not moan, or grasp) to painful stimuli, due to dimnished level of consciousness or sedation OR Limited ability to feel pain over most of body	2. Very Limited Reponds only to painful stimuli Cannot communicate Discomfort except by moaning or restlessness OR Has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of Body.	3. Slightly Limited Reponds to verbal commands, But Cannot always Communicate doscomfort or the. OR Has some sensory impairment which limits the ability to feel pain or discomfort over 1 or 2 Extremitiees.	4. No Imopairment Reponds to verbal commands, Has no sensory deficit whice would limit ability to feel or voice or discomford
MOISTURE Degree to which skin is exposed to moisture	1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc, Dampness is detected every time patient is moved or turned.	2. Very Moist Skin is often, but not always moist Linen munt be changed at least once a shift.	3. Occasionally Moist Skin is Occasionally Moist, requiring an extra linen change approximately once a day.	4. Rarely Moist Skin is usually dry, linen only requires changing at routine intervals.
ACTIVITY Degree of physical Activity	1. Bedfast Confined to bed.	2. Chairfast Ability to walk severely limited or non-existent. Cannot bear own weight and/ or must be assisted into chair or wheelchair.	3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance Spends majority of each shift in bed or chair.	4. Walks Frequently Walks outside room at least twice a day and inside room at least once every two hours during waking hours.
MOBILITY Ability to shangs and control body Position	1. Completely Immobile Does not make even slight change in body or extremity position without assistance.	2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent at significant charges independently	3. Slightly Limited Makes frequent though slight changes in body or extremity position independently.	4. No Limitation Makes major and frequent changes in position without assistance.
NUTRITION Usual Food intake Pattern	1. Very Poor Never eats a complete meal. Rarely eats more than 1/3 of any food offerd Eats 2 servings or less of protein (meat or dairy products ) per servings or less of proteint day. Takes fluids poorly Does not take a liquid dietary supplement OR is NPO and/or maintained on clear liquids or IVs for more then 5 Days.	2. Probably Inadequate Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR Receives less then optimum Amount of liquid diet or tube feeding.	3. Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy product) per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR Is on a tube feeding or TPN regimen which probably meets most of nutritional needs.	4. Excellent Eats most of every meal. Never refuses a meal Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
FRICTION & SHEAR	1. Problem is NPO and/or maintained on clear liquids or IVs for more then 5 Days.	2. Probably Inadequate Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR Receives less then optimum Amount of liquid diet or tube feeding.	3. Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy product) per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR Is on a tube feeding or TPN regimen which probably meets most of nutritional needs.