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Home > Simple Charting Checklist • Vitals • Pain Assessment • Peripheral IV Care (If Applicable) • CAM Asse

Simple Charting Checklist • Vitals • Pain Assessment • Peripheral IV Care (If Applicable) • CAM Asse

Vitals

Record blood pressure

Record heart rate

Record respiratory rate

Record temperature

Document oxygen saturation levels

Pain Assessment

Assess pain level using a scale (e.g., 0-10)

Document location of pain

Note characteristics of pain (e.g., sharp, dull, throbbing)

Record any alleviating or aggravating factors

Document pain management interventions provided

Peripheral IV Care (If Applicable)

Verify IV site for patency

Assess for signs of infiltration or phlebitis

Document the type and gauge of the IV catheter

Note the solution and rate of infusion

Record any dressing changes or site care performed

CAM Assessment

Conduct a brief CAM evaluation

Document any signs of delirium

Note the patient’s orientation to person, place, and time

Record any fluctuations in mental status

Assess and document any behavioral changes

Feel free to modify any items or sections as needed!

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