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Summary of positive data Cause of Admission Personal Data

Admission data

Co-morbid
conditions

GCS Pupils

Chest

Hemodynamics

Other
important Data

Assessment of Nervous System

Brain CT

GCS Motor
Verbal
Eye
Pupils
Gag reflex
Lateralization
Na level
Brain specific
therapy

Assessment of Cardiovascular and renal systems

Bp Input / 24hr
HR Output / 24hr
CVP balance
Auscultation Cumulative
ECG Intake /hr
Extremities Output/hr
Urea K
Creatinine Troponin
ECHO Data

Specific
Therapy
Assessment of respiratory system
RR SpO2
Auscultation
Oxygenation CXR
Or
Mechanical
ventilation

ABG

Specific
Therapy

Assessment For Sepsis

of 4 2 ..: :Sputum culture


: Urine culture
Tlc trend . :Blood culture
Possible Recent surgry Chest tube Foley's
sources of Pneumonia CVP Ryle
infection Bed sores Ext wound Lines
Antibiotics
used

Assessment of GIT and nutritional State

Abdominal Bowel
Examination Habits
Feeding ALB

ALT

AST

Assessment of Hematological System

Hemoglobin

Platelets

WCC
PC

INR

Anticoagulation