CHANGE OF CONDITION ASSESSMENT

1
DO NOT RESUSCITATE ORDER
YES
NO
Admission Date
Describe Change of Condition
Date Time Circumstances
2
Signature
Date
Time
3
Examples of a Change of Condition
(Non-inclusive)

• Change in Blood Pressure
• Elevated Temperature
• Fall with complaint of pain or unable to use limb
• Pain
• Weight Gain or Loss
• Chest pain
• Weakness in any area
• Blood in urine or stool
• Communicable Disease
• Urinary Frequency
• Urinary Fowl Odor
• Pain when voiding
• Depression Sadness, crying, withdrawn
• Upper Respiratory Infection
• Shortness of breath
• Grief, Loss of Loved One
• Pain down Left arm
• Injury
• Bleeding

• Change in hand grasps
• Change or unequal pupils

4
DO NOT RESUSCITATE ORDER
YES
NO
Admission Date
Dietary Restrictions (Diabetic/Mech. Soft, etc.)
5
Screening/Exams
Yes
Yes
No
No
Date
Date
Tuberculin Test (TB)
Stools for Occult Blood
Breast Exam
Dental
Pap Smears
Hearing
Mammogram
Vision
Yes
No
Artificial Limbs
Pacemaker
Catheter
6
Culture
Religion
Military
7
Review upon admission for any changes since date
of pre-admission assessment. Initial and Date
8
DO NOT RESUSCITATE ORDER
YES
NO
Admission Date
Dietary Restrictions (Diabetic/Mech Soft etc.)
9
Catheter
Oxygen
Tube Feedings
Culture
Religion
Military
10
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11
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