Intensive Care Unit Patient Assessment Form
Please complete the following assessment to record the patient's current clinical status in the ICU.
Level of Consciousness (Glasgow Coma Scale)
*
Please Select
15 - Fully alert
13-14 - Mild impairment
9-12 - Moderate impairment
3-8 - Severe impairment
Respiratory Support
*
Room air
Nasal cannula
Non-invasive ventilation
Mechanical ventilation
Pain Assessment (0 = No pain, 10 = Worst pain)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Sedation Level (Richmond Agitation-Sedation Scale)
*
+4 Combative
0 Alert and calm
-2 Light sedation
-5 Unarousable
Vital Signs
*
Rows
Value
Heart Rate (bpm)
Blood Pressure (mmHg)
Respiratory Rate (breaths/min)
Temperature (°C)
Oxygen Saturation (%)
*
Neurological Status
*
Normal
Confused
Delirious
Unresponsive
Pressure Injury Risk (Braden Scale)
*
Please Select
Very High Risk (≤9)
High Risk (10-12)
Moderate Risk (13-14)
Low Risk (15-18)
No Risk (19-23)
Current Infection Status
*
No infection
Suspected infection
Confirmed infection
Additional Clinical Notes
Submit Assessment
Should be Empty: