- Opening Note: Patient observed in bed. Bed is in lowest position, call light is within reach, bed wheels are locked, and patient’s personal belongings are at bedside. Patient’s respirations are even as well as unlabored. No acute distress noted at this time. Patient without complaints or concerns.
- Q2H Round: Patient rounded on bi-hourly from 0000 to 0700. Patient observed in bed, bed low, call light within reach, wheels locked, personal belongings at bedside. Respirations even, unlabored. No acute distress observed.
- Bed Alarm Activated: Bed alarm activated at this time, patient was found to attempting to ambulate to bathroom unassisted. Patient assisted to bathroom and then back to bed. Patient educated on fall precautions and the need to call for assistance before attempting to ambulate. Patient verbalized understanding. Bed low, call light in reach, belongings at bedside. Bed alarm re-armed at this time.
- 1 = Awake and alert. Acceptable; no action necessary; may increase opioid dose if needed.
- 2 = Slightly drowsy, easily aroused. …
- 3 = Frequently drowsy, arousable, drifts off to sleep during conversation.
- 4 = Somnolent, minimal or no response to verbal and physical stimulation.