DAILY PROGRESS & INCIDENT REPORT: PR-1 FORM

PATIENT EVALUATION GRADING SCALE

CLASSIFICATION OF PATIENT'S CONDITION AND SIGN & SYMPTOMS: Scale of: 0-1-2-3-4-5
0 EXTREME GRAVENESS
1 VERY BAD
2 BAD 
3 NORMAL (Level of Normality)
4 GOOD
5 EXCELLENT

REPORT

• VITAL SIGNS:
• H.R. (Heart Rate/min.):
• R.R. (Respiratory Rate/min):
• B.P. (Blood Pressure):
• FLUID INTAKE AND OUTPUT:
• FLUID INTAKE/24 HRS.: 
By Fluid Intake we refer to the approx. measurement of total amount of liquids/24 hours

Normal Fluid Intake (sedentary patient): (Normal day: a minimum of 1,500 ml to a maximum of 2,000 ml or 2 Liters).

Get to know the cc/ml the patient's glass uses daily - Ex.: If patient's glass is approx. 150 cc/ml, as any patient normally needs to take/drink from 1,500 to 2,000 cc/ml/24 hours, then 10 glasses = 1,500 
cc/ml or 1.5 Liters).
• FLUID OUTPUT/24 HRS.:
By Fluid Output we refer to the approx. measurement of diuresis (urine output)/24 hours. 

Approximate measurement of daily urine output can be "guesstimated" either by the duration of urination or by weighing a new, clean, diaper and comparing its weight to a wet, used, diaper, for example.

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 PROGRESS REPORT: CLASSIFY THE FOLLOWING EITHER BY GRADING (1 TO 5) OR BY DESCRIPTION (IN WORDS):
• GENERAL HEALTH STATUS (What impression of well-being or otherwise do you perceive the patient has today?):
0 1 2 3 4 5
• PATIENT'S COMPLAINT (Anotate any complaints - discomfort, pain, etc - the patient refers to you):
• SUBJECTIVE COMPLAINTS (Symptoms & complaints either refered by the own patient or perceived by third persons - family or caregivers. Specify: Nature, Location, Time & Probable Cause to the best of your knowledge):
   
• OBJECTIVE FINDINGS (Signs "manifested" objectively or seen - not perceived through the senses - by third persons. Specify: Nature, Location, Time & Probable Cause to the best of your knowledge):
   
• MOBILITY (Does the patient sit up &/or goes to CR on his/her own or is assisted? ....etc.):
0 1 2 3 4 5
• GAIT (Does patient walk normally - as before - or manifests limping, foot dragging, etc?):
 
0 1 2 3 4 5
• SPEECH:
0 1 2 3 4 5
• AWARENESS (Is patient alert, responsive & interactive?):
0 1 2 3 4 5
• RELATION WITH THE OUTSIDE WORLD (Is patient able to hold a conversation? Does patient manifest moods, affects, emotions?):
0 1 2 3 4 5
• AGITATION (PSICOMOTOR AGITATION) - An extreme form of anxiety, hyperactivity, nervousness capable of altering all bodily normal functions, i.e. BP, Heart Rate, Respiratory Rate, etc.):
0 1 2 3 4 5

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 INCIDENT REPORT (IF ANY): HAS THERE BEEN ANY SUDDEN INCIDENT OR NOTICEABLE CHANGE IN THE PATIENT TODAY? Explain to the best of your knowledge the nature of the incident:
• Time/Date/Place of Incident:
• Nature & Description of Incident (Use additional pages, if necessary:
• Brief description of probable cause (in your own words):

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 ADDITIONAL COMMENTS:
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