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Holes punched as per AS2828 1:2019
SMR110010
BINDING MARGIN – NO WRITING
, r 7 NSW OWE APd Health ‘laa %A 1 …mm., . FAHoles punched as per AS2828 1:2019
SMR110010 MILY NAME ..– (— i t ,. MRN <C61 1 i-k.- b GIVEN NAME –“ y…c.) .k 6i…„ rviAt. ED *MALE STANDARD ADULT GENERAL OBSERVATION CHART D 0 B ) _ % – V‘okk M.O. 1 fk_ ADDRESS ‹A -S1 w__L c…)-S-c Cr-INALD(1– 11 1lb – Altered Calling Criteria LOCATION NA ci.icisi_. ALL OBSERVATIONS MUST BE GRAPHED COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE MWAA Date I q, L9 Date Time ‘),o to Time Ion 12b 33-) A4°10 0)- Iffirffleal’,..- = = IY/BREATHING IRespiratory Rate – ita IME – 35 – 30 35 30 — -= Nil 1 mil 1 25 = 2015 e49 1:b 6 b ■111 ME20 15 – – 10 1 0 – 10 I – IIMI 100 In M Mil MINIM 100 – – 95 0 E) al l’ MEM Q) -95 — 90 ME II. In ‘MI 90 – 85 EMMEN = = 85 MI= MEM= IN11111111•111111 INIIIIIMMINIII O2Lpm or (1,1:1, 0.A a.p, 1,, (IA A EWA = mm m 02Lpm Devi e/ M EI . f (lAk MEM Ea 1MM in Devi e/ Key: RA = Room Air, NP = Nasal Prongs, FM = Simple facemask, NRB = Non Re-breather, VM = Venturi Mask M i== Mi 1 230 220 21 -230 220 MIMMI WM= – – 210 1 = Ell – 200 IN 1•1111111111M — –M 20 19 4, 1-190 en MI= =——…– •Ecn 1— 180 —170 . 170 8 co 0- – 160 16 Pi):1 -150 =mill MN MIMI MMIIIMMIll. 15 T – 130 Elf la M = MIMI= = 13 – 120 111 11 1/ 1 12 Z 0 JP I _1 E e 6n3 CD ti •0 ° 2 co110 11 – —100 1 111 1 Ili 10 90 90 – 80 NM 80 -In :%Mil.MMI MO M 70 1 ru 1_ 60 lil ME IIIIMIIIIIIIMMI – IlminingliNIMMEMMINi 111111111 1M M IN MIU MMIIIII EMI 60 50 011 NE 50 ce 5 . 2 rem r co I Rhythm M 11111MM 11111111111MINI 160 – 160 1- – 150 IMII MIMI EM INIIIIIIMINIIIII 150 140 1M 1.1 M _ 140 — – 130 Mil MIN M MI 130 1.1111111MMI MIN – 120 – 110 IP ilii IMI 120 – 100 II iMi 110100 – P 65) 11111 11 90 – 80 – 70 60 50 0 0 80 I-II I 70 – 1 MEM III 1 60 50 – – 40 40 – A o 0 0 0 (2) 0 I111 11 A C C DISABILI [ Neurologi V V P =MI II.U =MM IMM E•1• MNI111111MM N=NM U A= Alert, C= new confusftinicbange in behaviour, V= Rousable by voice (conduct GCS). P= Reusable on4 by pain (conduc1 GCS). U= Unresponsive Initials p 1 a (…, 6.3 r., 1,_ , ,•… [ ,_ —I 1 1 1 1 –1 1 Initials
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4111 NS.W Health FAMILY NAME It, P– r MRN C61 i 3zi b GIVEN NAME h IA I,/ 9-24 CA 9 LA M.O. -‘—.46ciAL ❑ MALE FEMALE – STANDARD ADULT GENERAL OBSERVATION CHART DOE A ADDRESS LT – M…4.1..) •-1– Altered Calling Criteria LOCATION pQA(f2., ALL OBSERVATIONS MUST BE GRAPHED COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE I (kKuki- Date `)-O L0 Time k lA N N • 6 I R t 61 Date Time gA ‘,I 1._ _ 24 () I zt_ i0,- 0 0 “0 EXPOSURE 1 Temperature (°C) • 41 41-: – I 40.5– 40.5 40 40 – – — 39.5 -I 39 39 – – 1 38.5 – 1-38. 38 — 37.5 , 37.5 -. — – _ —0 0 G_L — — 37 _ 36.5 -• – 36.5 36 – 36′ 35.5 -35 – 35 I 34.5 – 34.5I 34 – 1 — u!ed Assess pain level at rest and with movement. Enter R for at rest, M for movement Severe (7-10) 1ve Sere (-1 70) Moderate (4-6) /4 r.4 q Moderate (4-6) Mild (1-3) Mild (1-3) Nil INo painInitials c6 (-0 p ,,, 1 ”” Initials Blood Glucose] Date Time BGL 16 Date Time BGL l tt 4 IIsiamog Date Date Date ■ Daily Date Daily F- Urinalysis 1 Date 1 ‘)■) rb W Date Time (y/2„,-2.,0 Time SG , 0 vo PH -1 PH Leuk _ Leuk Blood Blood Nitrite Nitrite Ketones Ketones Bilirubin Bilirubin UIBiI _ U/Bil Protein Protein Glucose Glucose
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