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patient health and safety assessment

I. Patient Identification and Information

Confirm patient identity (name, date of birth, medical record number)

Review medical history and current medications

Assess allergies and adverse reactions

II. Vital Signs Assessment

Measure and record blood pressure

Measure and record heart rate

Measure and record respiratory rate

Measure and record temperature

Assess oxygen saturation levels

III. Physical Examination

Conduct a head-to-toe assessment

Check for signs of distress or discomfort

Evaluate mobility and functional status

Inspect skin integrity and wounds

IV. Safety Risk Assessment

Identify fall risk factors (e.g., history of falls, mobility issues)

Evaluate environmental safety (e.g., clutter, lighting)

Assess for potential allergies (e.g., latex, environmental)

Review use and need for assistive devices

V. Infection Control Measures

Confirm hand hygiene practices are followed

Assess need for personal protective equipment (PPE)

Review isolation precautions if applicable

Ensure proper sterilization of medical equipment

VI. Patient Education and Communication

Confirm understanding of diagnosis and treatment plan

Provide information on medications and side effects

Discuss health maintenance and preventive care strategies

Encourage questions and address concerns

VII. Emergency Preparedness

Review advanced directives and resuscitation preferences

Ensure emergency contact information is up to date

Discuss potential emergency situations and response plans

VIII. Documentation and Follow-Up

Document findings in the patient's medical record

Schedule follow-up appointments as needed

Communicate assessment findings with the healthcare team

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