DAILY NURSING ASSESSMENT

FLOWSHEET
(complete each shift)
0700 – 1900 1900 - 0700
MENTAL STATUS MENTAL STATUS
Orientation: Memory: Activity: Orientation: Memory: Activity:
Time/Date Impaired Cooperative Time/Date Impaired Cooperative
Place Intact Uncooperative Place Intact Uncooperative
Person Threatening Person Threatening
Social Social
Affect: Thinking: Withdrawn Affect: Thinking: Withdrawn
Inappropriate Logical Aggressive Inappropriate Logical Aggressive
Appropriate Grandiose Lethargic Appropriate Grandiose Lethargic
Depressed Concrete Hyperactive Depressed Concrete Hyperactive
Euphoric Tangential Limit-testing Euphoric Tangential Limit-testing
Frightened Blocked Manipulative Frightened Blocked Manipulative
Sarcastic Confused Disruptive Sarcastic Confused Disruptive
Labile Loose Labile Loose
Flat/blunted Persecutory Eye Contact: Flat/blunted Persecutory Eye Contact:
Anxious Paranoid Good Anxious Paranoid Good
Constrict Pressured Fair Constrict Pressured Fair
Suspicious Fleeting Suspicious Fleeting
Angry Judgement: None Angry Judgement: None
Poor Poor
Adequate Adequate
Suicidal (describe): Suicidal (describe):

Self Injurious (describe): Self Injurious (describe):

Homicidal (describe): Homicidal (describe):

Hallucinations (describe): Hallucinations (describe):

Delusions (describe): Delusions (describe):

0700 – 1900 1900 - 0700

Attend 2 or more groups: Y N Y N
Attention to task (10 minutes +): Y N Y N
Can retain 1 step directions : Y N Y N
Responds beyond YES or NO: Y N Y N
Initiates conversation: Y N Y N
Short-term memory: WNL Impaired Intact Y N Y N

________________________________
Patient Name

________________________________
Date
 PHYSICAL STATUS PHYSICAL STATUS
Appearance: Gait: Ambulation: Appearance: Gait: Ambulation:
Neat Steady Unassisted Neat Steady Unassisted
Clean Shuffling Assisted Clean Shuffling Assisted
Disheveled Unsteady Wheelchair Disheveled Unsteady Wheelchair
Bizarre Walker Bizarre Walker

Speech: E.P.S. Eval: Other: Speech: E.P.S. Eval: Other:

Clear/norm N/A ___________ Clear/norm N/A ___________
Pressured No signs ___________ Pressured No signs ___________
Slow Fine Tremor ___________ Slow Fine Tremor ___________
Soft Facial twitch Soft Facial twitch
Mute Restlessness Mute Restlessness
Fast Rigidity Fast Rigidity
Loud Drooling Loud Drooling
Slurred Shuffling Slurred Shuffling

Vital Signs
B/P
Time T P R B/P lying B/P sitting standing Initial

Lab Drawn: Yes No UA Obtained: Yes No

Weight: _______________________

0700 – 1900 1900 - 0700

Diet: document % taken (S = snack, B = breakfast, L = lunch, D = dinner B=% S=%
L=%
[ I ] Independent [A] Assist S=%
D=%
Health Shake: Yes No
Last Date of Mensus: Currently on Mensus Yes No
Output / Stool:
Output / Urine: [ C ] Continent [ I ] Incontinent
Hours of Sleep: (write number of hours slept) Onset
ADL’s: [ S ] Self [ A ] Assist [ TC ] Total Care
Shower: [ S ] Self [ A ] Assist [ TC ] Total Care

0700 – 1900 1900 - 0700

Staff Signature Initials Staff Signature Initials

revised 7/22/99 f:group\phf\forms\flowsheet