Commonly used documentation points to assist with charting.
Assault:
No incidence of violence or aggressive behavior noted at time of assessment. Patient advised that violent behavior will not be tolerated, patient verbalized understanding.
SI/SH:
Patient denies SI/SH at the time of assessment. Pt is calm and cooperative. Pt agrees to seek staff assistance if SI/SH/AVH occur.
Elopement:
Patient has not voiced an intent to elope. Pt stays away from exits and has not been door testing. Pt accepts redirection from staff.
SAO:
No incidents of witnessed SAO behavior this shift. Patient does not exhibit sexual activity, inappropriate speech, or disrobing in view of peers and staff.
Vulnerable:
Patient does not appear physically frail, disoriented, or impaired mobility at time of assessment. Pt not wandering or verbally provoking witnessed or reported during this shift.
Cheeking:
No evidence of cheeking observed or reported during this shift. Patient accepted and swallowed all medications under direct observation. No signs of medication hoarding or non-adherence noted at time of assessment.
Seizures:
No seizure activity observed or reported during this shift. Patient remains alert and oriented. Seizure precautions to remain in place.
Patient asleep; unable to assess:
Unable to assess, client found to be sleeping at time of this assessment, Respirations are even, unlabored. No signs that patient is in acute distress at time of assessment.
Falls:
Patient without falls during this shift at time of assessment. Donning non-slip footwear and utilizing wheelchair/walker to ambulate appropriately.