Penyakit Kronik Bilangan paracetamol yang diambil Tarikh sakit kepala Berapa bilangan kali sakit kepala Please select nursing diagnosis and enter Date & Time, Date and Time Start, Related To, Goals and Intervention for each Diagnosis Doctor Completed Form Nurse Transferring Patient #Date of Extubation will be the date of the most recent extubation *LOT - Limitation of life sustaining therapy Satisfied with handover Next of Kin Aware Primary Team Aware Physio Outstanding Investigations Dentures Recorded Latest RBS Pressure Areas Drain Sites Wounds Urine output > 0.5ml/kg/hr Date Of Insertion Catheter Site Last HD RRT CBD Infusion Type Temp CVP BP HR No. of Peripheral Lines CVL Aim SpO2 Aim pO2 Resp Rate Via Inner Canulla #Date of Extubation Trac. Tube Size Disability Change to chronic therapy PMH Operative Procedure Investigations History of ICU Stay Reason for Admission & Current Concern Situation LOT* Status Transferred to: Date & Time of Transfer: Date of ICU Admission: Musculoskeletal Description Abdomen / Genitourinary Description Respiratory Description Cardiovascular Description Nervous Description Neurological Investigation Obstructed Airway In severe dementia, they cannot do personal care without help. In moderate dementia, recent memory is very impaired, even though they seemingly can remember their pass life events well. They can do personal care with prompting. The degree of frailty corressponds to the degree of dementia. Commond symptoms in mild dementia include forgetting the details of a recent event, though still remembering the event itself, repeating the same question/story and social withdrawal. Scoring frailty in people with dementia Clinical Frailty Scale Not Intubated Behavioral Pain Score Inflammatory Markers ICU Day Subcutaneous Infusion Hand over Time Hand over Report Scale Cardiac Arrhythmia Perioperative Stabilization RVD Myasthenia Gravis Chronic Liver Disease Chronic Lung Disease Esrf Ptb CCF IDH Admitting Diagnosis Site Site Comment MRC Comment ECOG Functional Status and Dependance Diagnosis Upon Admission Reason for Admission Referred From Subspecialities Primary Discipline Indication for Audiological Assessment Requested By (L) (R) Tuning Fork Test Rinne Audiological Services Required Exomphalus: Potential infection Demo Care baby of Pneumothorax: Ineffective breathing pattern Demo Diabetic Education Other Relevant Information Employed (freetext) Immunology Clinical SLE Presentations Date Not Given Date Given Please Select DIABETICS EDUCATIONS Samples Labelled & Packed by History & Presenting Complaint Past Surgical & Obstetric / Menstrual History Termination of Resuscitation Transport Radiology Investigations Plan Trimester Designation Designation Designation Samples Labelled & Packed by Samples Labelled & Packed by Critical Onset Ascites / Free fluid Cervical Length Appears to 'sing' Starts to respond with vocalizations when called by name Type of Order Procedure Plays more games, e.g. peek a boo, hand clapping, etc. and vocalizes during games Repeats CV syllables in babble [pa pa] Vocalizes when alone or with others Vocalizes in response to speech Starts to use a variety of vocalizations to express pleasure and displeasure Blows raspberries, coos, yells Vocalizes in response to singing Vocalizes for needs and wants Occasionally vocalizes in response to voice-like sounds Begins to Localize to Express Pleasure Cries To Express Hunger and Anger Serum Creatinine Type of Examination Descriptive Report Contrast Volume Contrast Name Indication/Relevant Clinical Study Protocol Reporting Doctor Volume (Ml) Site If Apgar Score > 20 minutes Genitalia Examination Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Total Plan Plan Goal Setting Session Analysis Progress Summary Past Obstetrics History Remarks by Nurse Changes Medication Tear Film Assessment (Method) Tear Film Assessment (Method) Corneal Sensation (Method) Corneal Sensation (Method) CCT (Method) CCT (Method) Specify History & Physical Examination Volume Volume Volume Response Team Mission Abort Reroute Other Enhancement: Other Services Already at Scene Number of Patient at Scene Other Agency Type of Service Response Enroute At Scene At Patient Transporting Dispatch Time Position Of Cervix Length Of Cervix (Cm) Cranial Nerves and Neurological Examination Pinhole Pinhole Duration of Contraception Discontinuation Other blood tests Renal Profile (RP) Lactate Dehydrogenas (LDH) Comments Comments Comments Comments Date of Confirm RR > 25 MEWS > 3 Sob/Lethargy New/Persistance Temperature SPO2 < 95 Increase CRP ALC < 1.0 Increase Ferritin CXR Worsend PF Ratio < 300 Mental Health Assessment Do you sleep well ? Are you able to eat well ? Are you able to control your emotion ? Do you need any help ? *** Please asses patient's mental health status daily Comments Perineum Ultrasound Position Of Gaze Significant Weight Gain (>10%) In Last One Year REFLEXES/BRISKNESS Female Male Bone Marrow Aspiration TW Sample No of Babies Delivered Lower Segment Peritonial Cavity Type of Caesarean Section Anaethesia (Type) Indication For Surgery Date Time Finished Date Time Started Engagement of Presenting Part Placental Site Placental Abnormality Type of Operation Post-operative Diagnosis Pre-operative Diagnosis Gross Specimen Date Time Post Operative Notes Post Operative Diagnosis Pelvic Peritonium Right Tube Left Tube Uterus Uterus Operation Finding Moro's Reflex Tone & Movement Children Children General Examination Ophthalmoplegia Proptosis Neck Examination Pretibial Myxoedema Mean Bp (mmHg) Systolic (mmHg) Diastolic (mmHg) Bleeding Complication (TIMI Criteria) Final Diagnosis at Discharge Total number of overnight stays ICU / CICU CCU Number of overnight stays Intubated Detail Date & Time ROM PEFR (If Indicated) (L/Min) Ticagrelor Specify Specify Specify Specify Specify Specify Specify Specify Specify History Of Thyroid Disease Present Pregnancy Neck Ct Scan Thyroid Histology Thyroid Fnac Histopathology Neutrophils Anti-Tsh Receptor Ab Anti-Tg Ab Anti-Tpo Ab Blood Results Total No. of Days of Nitric Oxide Organ Involved Pulmonary and Extra Pulmonary REFLEXES/BRISKESS Thoracic Malignancy Assessment Thoracic Malignancy Assessment Date and Time Surgery Date And Time Ended Date And Time Started Monthly Income Occupation Education Religion Pills General and Systemic Examination Accompanying Person To Hospital Samples Handed Over To Police Officer Samples Handed Over To Police Officer Total No. of Samples Total No. of Samples Type of Clothes Collection of clothes Amniocentesis Tap Cardiovascular (CVS) Date and Time Surgery Age of Admission Delivery Type Preliminary Report Person(s) Present During Examination Laterality Laterality Laterality Laterality Laterality Laterality Instrument Set Swab Count Comments Regarding Referral Birth and Childhood History Ckd Retardation Factors Ckd Current Renal Function Treatment/Procedure Cpr Log AAEBRI First Used Substance Birth and Childhood History (Where Relevant) Number of Previous Attempts (ISH) CPR Cycle Other Actions Injuries Injuries Intervention Circulation Intervention Breathing Intervention Airway Intervention Position of Fetal Head Position / Comfort Intervention Position / Comfort Leaking Liquor Phone No Activation Time Activation Time Type of Malignancy Total no of days of CPAP/Bilevel CPAP Ventricles Size (mm) POG of Booking Palpable Conjunctival Hemorhage Head Swelling, if present Police Report Psychiatric illness Dapsa TIMI Risk Score Machine Used Formula Used History Investigation Result Rheumatology Past History Postductal Left Leg SPO2 (%) Postductal Right Leg SPO2 (%) Preductal Right Hand SPO2 (%) Imperforate Respiratory Rate (breaths/min) Heart Rate (beats/mn) Birth COH (cm) Exam Date/Time Tinnitus Functional Index (TFI) 33cm Collection of Forensic Samples Collection of Forensic Samples Comments Family Patient Consent Family Dynamic Realistic Expectation Team Members Involved soft Contact Lens Binocular Single Vision Cognitive Behavioral Therapy Tinnitus Retraining Therapy Visual Analogue Scale For Tinnitus Annoyance (1: NOT ANNOYING, 10: EXTREMELY ANNOYING) Visual Analogue Scale For Tinnitus Annoyance (1: NOT ANNOYING, 10: EXTREMELY ANNOYING) Visual Analogue Scale For Tinnitus Loudness Perception (1: INAUDIBLE, 10: EXTREMELY LOUD) Visual Analogue Scale For Tinnitus Loudness Perception (1: INAUDIBLE, 10: EXTREMELY LOUD) A-scan Final Axial Length Reason for not transporting Disaster Triage Case Outcome Prescription Ear Non Shockable Shockable Non Shockable Shockable Airway Management DNAR Witnessed Arrest Bystander CPR CPR End Rhythem Analysis CPR Start Type of Response Slit-Lamp Status Of Vascular Zeamays to Maize Laboratory Postfilter Prefilter Which ear is louder: GLP1-RA Insulin Regimen Injectable Antidiabetic Agent Injectable Antidiabetic Agent Activity General Condition General Condition NR=No Response X=False Positive RAPD Preliminary Test Lens Parameter Verification Left Eye Distance Right Eye Distance Aim & Goal Aim and Goal Brief Medical History 2 or 3 0 or 1 Maternal Hepatitis Reactive Maternal Vdrl Fall Risk (Kindly ensure Humpty Dumpty Scale is performed) Comments What Is The Nature Of The Tinnitus? What Is The Nature Of The Tinnitus? Tinnitus Assessment Tinnitus Assessment Domestic Problem Social Problem History of Nicotine Replacement Therapy History of Nicotine Replacement Therapy Current Drug of Use Age of First Use Type of Substance Use (Lifetime) 24 HUP (g/day) LDL (mmol/L) Cholestrol (mmol/L) HBA1C (%) FBS (mmol/L) Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Patient Demographic Developmental Milestones (Where Relevant) Duration of Untreated Illness (eg. Duration of Untreated Psychosis) Word Count 3 Months Medications Related to Osteonecrosis of the Jaw (MRONJ): Loss of Appetite ACR/EULAR Nearest Health Clinic **Calculation regarding anthropometry invalid if height <150cm Total no of days of Oxygen Theraphy Total no of days of CIPAP/SIPAP Ambulance Mode of Transport to Hospital blast Penetrating Mechanism of Injury Fax Postal Address Total Word Count *Risk indicators that are marked with an asterisk are of greater concern for delayed onset hearing loss - refer even if pass screening. If High Risk, please tick (/) the risk factors: HRHNS Doctor's Name Screener's name Consent for Operation Procedure Common Future Calender Date And Time Date And Time Date And Time Date and Time of Assessment Mix Feeding Discharge Baby To Sexual Transmited Disease Type of Crime How many times? How many times? Whether on Substitution Treatment Type of substance When was the last use? Samples Handed Over To Police Officer Distant VA DOB Central Nervous System (CNS) Time of First Defibrillation Time of ECG Body Annotation Perempuan Lelaki M34.8 M34.1 M05.3 M05.2 M05.1 Others Table Are they acute injuries? Are there any anal injuries? Do the anal injuries indicate Sign of blunt trauma? NAMA / NAME: Occupation History Investigation of Maternal Death Performance Status (Ecog) Comments As Above As Above As Above Anatomy Structure & Physiology Anatomy Structure & Physiology Barthel Score Occupation/Financial Coverage Normal Other and Functional Assessment Date And Time Restraint Ended Method Diagnos Check Age Age address nama 1. Risk Of Violence / Harm To Others Number of years smoked Number of cigarettes smoked per day For Smoker And Ex-Smoker Exomphalus: Potential infection Hydrocephalus: Emotional disturbance of parents Hydrocephalus: Potential of increasing intracranial pressure Hydrocephalus: Potential pressure injury over the head Hydrocephalus: Altered comfort Hypothermia Hyperthermia degC Balanz® Nutrineal® Physioneal® Icodextrin® Volume Of Each Bag: Volume Of Each Bag: Volume Of Each Bag: Volume Of Each Bag: Volume Of Each Bag: Volume Of Each Bag: Volume Of Each Bag: Volume Of Each Bag: Volume Of Each Bag: Do rectal examination Take smear from introitus Do not proceed for further vaginal examination Strasberg Classification Number of years smoked Number of cigarettes smoked per day HB, WBC, PLT Smoker/Vape Community Psychiatry Referral Letter Perform Location Date of Completion Date of Injury Nutrition Intervention (Plan) Monitoring & Evaluation Nutrition Focused Physical Findings Nutrition Related Biochemistry Breakfast / Lunch / Dinner / Morning Tea / Afternoon Tea / Supper Time Spent Time Spent Time Spent Time Spent Time Spent Time Spent Time Spent Time Spent Leg Swelling Weight loss, amount (kg) Weight gain, amount (kg) Lost of appettite (LOA) Fatigue Fever Chronic Kidney Disease (CKD) Renal Impairment Osteoporosis Non Alcoholic Fatty Liver Disease Epilepsy Peptic Ulcer Disease Cerebrovascular Disease Chronic Obstructive Pulmonary Disease (Copd) Tuberculosis (Tb) Asthma Ischaemic Heart Disease Hypertension (HPT) Dyslipidaemia Diabetes Mellitus (Dm) Baseline Result Type of Radiation Effect Effect Effect Effect Effect Duration Duration Duration Duration Duration Blood Result 4. How do you describe yourself the way you eat food? 3. Have you ever wake up in the night to eat? 2. Do you eat when you are in situation? 1. Where do you normally have your meal at home? 8. Willingness to come for follow up 7. Willingness in increasing physical activity to assist in weight loss 6. Level of knowledge on food and obesity (base of knowledge assessment form) 5. Level of understanding on the risk associated with obesity. 4. Support network 3. Dieting attempts 2. Stage of readiness to change nutrition-related behavious 1. Reason to lose weight Please Tick Accordingly Needs Verification Notes for Follow Up Relevant Investigation Cause of Death Allergic and Adverse Reaction Food Intake Nutrition Assessment of Diet Intake Diet Recall Food Frequency Patient Has Attended Dietary Group Education Patient's Group Education Session Comments Comments Comments Comments Comments Comments Impression Impression Impression Impression Impression Impression Estimated Birth Weight (kg) Monitoring and Evaluation Assessment on Progress (Anthropometry/Biochemical/Clinical/Dietary Estimated Requirement Summary Of Nutrient Intake Name of Staff Who Ended Observation Name of Staff Who Initiated Observation SHIM/IIEF-5 Chart Others, please specify Tab Olanzapine Orally Disintegrating Im Zuclopenthixol Acetate Im Ziprasidone Tab Midazolam Im Midazolam Iv Midazolam Im Haloperidol Iv Haloperidol Iv Diazepam Splenectomy Weekly Dose (mg) Volume transfused Specify Specify Specify Humphrey Visual Field Automated Visual Field Schedule Of Monitoring Complications Procedure Stop Time Procedure Stop Time Procedure Start Time Procedure Start Time Place Of Treatment Other Unemployed reason During Menses Medical Diagnosis Medical Diagnosis Pharmacological Treatment At Notification Comments Comments Comments Comments Comments Comments Comments Comments Duration and Location Duration and Location Duration and Location Duration and Location Duration and Location Transfer/Referred Rhinology Signature (By ETD Doctor) If yes, look in the following areas: Laryngology Surgical History Contraception Severe Moderate Moderate Moderate Mild Mild Mild Normal Normal Voice consistently SOUNDS normal AND does NOT CALL attention TO itself. Patient able TO participate IN social activities requiring low OR high vocal demands which IS NOT limited BY his/her voice. Prolactin Testoserone FSH Voiding Difficulty Comments Comments Date of Last Pap Smear Samples for Baseline UPT and STI Samples for Baseline UPT and STI Reference Samples for DNA analyses Sampling for alcohol and toxicology analyses Collection of samples from the internal anus Collection of samples from the external anus Collection of Forensic Samples Collection of samples from the vagina Swabs from vulva Swabs from the penis Pubic Hair Cuttings Pubic Hair Combings Collect 3 swabs from oral cavity Plucked / Cut Head Hair Dia Kalah, Tetapi Telah Dianugerahkan Sebotol Bola Tenis Sebagai Hadiah Saguhati. Adam Menang Dua Perlawanan Pertama, Tetapi Disingkirkan Pada Perlawanan Ketiga. Aril Berjaya Melayakkan Diri Ke Separuh Akhir. Hearing Loss (NORL) Abnormality Abnormality Abnormality Abnormality Jangan Cuba Memasukkan Hasil Penulisan Yang Tersasar Dalam Pemarkahan. Penjelasan Kualitatif Seperti Berikut. Jika Pesakit Dapat Melakukannya Dengan Mudah, Tanya 5 Soalan Untuk Membantu Pesakit. Huruf Atau Nombor Yang Ditulis Oleh Klien Itu Sama Ada Betul Atau Salah. Selepas Itu, Pesakit Perlu Membacakan Soalan Dan Pilihan Jawapan (Seperti Yang Dilakukan Oleh Terapis) Tanpa Bantuan. Markah Diberi Jika Respon Difahami. Kesalahan Artikulasi Direkodkan. Mereka Membeli Ayam, Sayur Kobis Dan Buah Epal. Kemudian, Mereka Singgah Makan Tengahari Di Gerai Pak Mat. Mereka Pulang Ke Rumah Dan Siti Memasak Nasi Ayam. tayar kereta mereka pancit. Walaubagaimanapun, mereka sempat tiba di stesen keretapi dan Ali pun sempat menaiki keretapi tersebut. Auscultation Mental Main Mind Mental Main Mind Others, specify Trial Lens Specification Symphysis Fundal Height Fundal Height Comments Comments Comments Comments Pitch Pattern Sequence Test Gap In Noise Digit Span Test Double Dichotic Digit Test Masking Level Difference - 500 Hz For What Receptive Language Skills Word Count (every 3 months) 3months Outcome Location Provisional Diagnosis Comments Borang Harta Benda Pesakit Comments Comments Comments Comments End Date Start Date Plan_4461 Severity Direct Selection Symbol SFA Result Trauma Management Mode Of Arrival At Hospital Emergency Medical System (Ems) By Ultrasound By Ultrasound By Dates By Dates Comments Comments Comments Comments Comments Comments Tarikh / Date Nama / Patient Name Jantina / Sex Tarikh Lahir / Date of Birth Alamat Rumah / Home Address Tel. Number Sebab Kecacatan Penglihatan / Vision Loss Due To Lain Kecacatan / Any Other Handicap Keterangan Ibubapa / Penjaga / Details of Parent / Guardians Nama / Name Pekerjaan / Occupation Alamat Majikan / Employers Address Telefon / Telephone Riwayat Kesihatan Keluarga Jika Ada / Family Medical History If Any Dilapor Oleh / Recorded By No. Pendaftaran Buta / Blind Registration No. Sensory Level: Distribution Of Sensory Deficits Year Year Year Year Year Year Year Year Year Year Year Yes Exchange Transfusion Fall Risk (Kindly ensure Morse Fall Scale is performed) Toilet Training Medical Device Medical Device Medical Device Medical Device LMP Yes Self Harm Parent / Caregiver Educational Background (Highest Education) Varicocele Method Family's Expectations Yes No. of Cigarettes Per Day Cleft Mandible Orbit Eye Soft Tissue Maxilla Specify Distribution 6. Others, specify Others, specify Others Others Digits Digits Tone Tone Movement Movement cm below left costal margin cm below right costal margin at mid clavicular line Appoitment Date Monitoring Monitoring Monitoring Monitoring Total Daily Dose (mg) Total Daily Dose (mg) Mean Daily Dose / kg Mean Daily Dose / kg Mean Daily Dose / kg Current Dose Current Dose Current Dose Other, specify Other, specify Comment Comment Comment Comment Comment Comment Arrive at Hospital Depart from Scene Arrive to Patient Arrive to Scene Depart to Scene Activation Activity Mode of Arrival at Hospital Type of Admission Age of Admission Date of Admission Time of Admission Type Of Injury Place Of Injury Mechanism Injury Injury Intent Age At Injury Others Order Information Case Type Problem List Number of Attempt Number of Attempt Location Tube Size (F) Tube Size (F) Location Anchor Lever (cm)