住院患者再评估及出院评估表一、一般患者资料科室：[hls_v_admission_discharge].[NAME]性别:□男√女年龄:[hls_v_admission_discharge].[INFONATION][hls_v_admission_discharge].[JOB][hls_v_admission_discharge].[SEX]住院号：[hls_v_admission_discharge].[PATIENT_ID]入院诊断：入院时间：信息采集:□责任护士□其他护士[hls_v_admission_discharge].[INFORCOLLECTION]入院方式：□步行□轮椅□平车□背入□扶入[hls_v_admission_discharge].[TIMES][hls_v_admission_discharge].[HOSPITALMODE]二、病情变化时评估由普通病例转变成为危重病例:□无□有：[hls_v_admission_discharge].[CRILCASE_NOTE][hls_v_admission_discharge].[ISCRILCASE]意识状态：□清楚□谵妄□嗜睡□烦躁□意识模糊□浅昏迷□深昏迷□其他[hls_v_admission_discharge].[MIND]自主意识：□正常□全瘫□截瘫□偏瘫□其他营养：□良好□中等□消瘦□恶病质[hls_v_admission_discharge].[CPCYWILL][hls_v_admission_discharge].[NUTRITION]语言沟通：□正常□失语□含糊不清□手势语睡眠：□正常□不稳□失眠□服镇静剂[hls_v_admission_discharge].[VERBALCOMM][hls_v_admission_discharge].[SLEEP]大便：□正常□便秘□腹泻□失禁□造漏口小便：□正常□失禁□尿潴留□留置尿管[hls_v_admission_discharge].[FECES][hls_v_admission_discharge].[PEE]患者对疾病认识:□完全□部分□不认识□未被告知情绪：□镇静□激动□焦虑□恐惧[hls_v_admission_discharge].[AWAREDISEASE][hls_v_admission_discharge].[EMOTION]体格检查:T℃P次/分R次/分BPmmHg[hls_v_admission_discharge].[WEIGHT]皮肤情况:□无□异常：[hls_v_admission_discharge].[SKIN]管道情况:□无□有：辅助检查阳性结果:□无□有：病情观察：□及时□不及时执行医嘱：□及时□不及时输血：□无□有：其他特殊治疗：□无□有：护患沟通：□良好□欠佳□没有沟通□无法沟通□其他心理干预：□是□否会诊：□无□有会诊科室：□院内：□院外：转科：□无□有□转科：□转院：评估护理等级：□特级护理□一级护理□二级护理□三级护理评估病情等级：□一般□病重□病危护理方面：管道脱落：□无□有：跌倒：□无□有：压疮：□无□有：坠床：□无□有：护理
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：护理措施：[hls_v_admission_discharge].[APOSASSESS_TIME][hls_v_admission_discharge].[APONURSESIGNATURE][hls_v_admission_discharge].[HEADNURSESIGN]三、出院前评估意识状态：□清楚□谵妄□嗜睡□烦躁□意识模糊□浅昏迷□深昏迷□其他自主能力：□正常□全瘫□截瘫□偏瘫□其他体格检查:T℃P次/分R[hls_v_admission_discharge].[OUTR]次/分BPmmHg[hls_v_admission_discharge].[OUTWEIGHT]皮肤情况:□无□异常：管道情况：□无□有：诊断：入院：出院：疗效判断：□痊愈□好转□转院□自动出院□死亡□其他出院指导、随访：[hls_v_admission_discharge].[OUTASSESS_TIME][hls_v_admission_discharge].[OUTNURSESIGNATURE][hls_v_admission_discharge].[OUTHEADNURSESIGN]
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